July 23, 2021: Our quality measure strategy in the US is NOT working. We need to shift from a process-oriented focus to focusing on eliminating low value care and easing clinical data entry burden. Dale Sanders, Chief Strategy Officer at IMO brings his military, technology strategist and data expertise to the subject. A recent IMO and HIMSS survey reported issues with inconsistent data due to subjective documentation from providers. Despite these issues, organizations are using patient data for quality measurement and reporting (81%), revenue cycle management (60%), and clinical decision support (55%). Is there no silver bullet for improving the quality of data? Will we continue to struggle applying AI until we get a higher quality? There was a lot of confusion around data during the pandemic. What would a much better scenario look like for US healthcare if we see another global pandemic in our lifetime?
Dale Sanders on Data Quality, Standards and Collection Through the Pandemic
Episode 427: Transcript – July 23, 2021
This transcription is provided by artificial intelligence. We believe in technology but understand that even the smartest robots can sometimes get speech recognition wrong.
[00:00:00] Bill Russell: [00:00:00] Thanks for joining us on This Week in Health IT influence. My name is Bill Russell, former healthcare CIO for 16 hospital system and creator of This Week in Health IT, a channel dedicated to keeping health IT staff current and engaged. We are joined by Dale Sanders, former CTO at Health Catalyst, new role Chief Strategy Officer for IMO.
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[00:01:36] We are joined by Dale Sanders, former CTO at Health Catalyst, new role Chief Strategy Officer for IMO. Dale, welcome back to the show.
[00:01:44]Dale Sanders: [00:01:44] Thanks Bill. It’s good to be here. It’s always fun to hang out with you.
[00:01:48] Bill Russell: [00:01:48] Wow. It’s been a while and some things have changed. So I’m looking forward to talking about your new role and what you’re doing. What are some of the things that you’ve been doing? So let’s start there. You’ve [00:02:00] made a transition and tell us a little bit about the transition.
[00:02:05]Dale Sanders: [00:02:05] Yeah, so I was consulting for IMO for about six months and then we jointly decided it would probably make more sense for me to be a formal branded part of the company.
[00:02:18] And so I went from being consulted to taking this Chief Strategy Officer role. Which is kind of interesting because historically I’ve always associated Chief Strategy Officer roles for we’re putting you [00:02:30] out to pasture, or you’re not a very good operator. So we’re going to put you over here in the corner and we’re gonna keep paying you, but we’re really not going to listen to you.
[00:02:37] So that was sort of my bias of chief strategy officers, but to Anne Barnes and the rest of the executive teams credit, they wanted me to be more operationally involved. And I said, I my, I I’m okay with that but I’m a late in life first-time father I’ve sacrificed a lot of time away from my five-year-old and seven year old [00:03:00] kids.
[00:03:00] And I just don’t want to get deeply involved in an operator role right now. So if you’ll give me the influence without the operational responsibility. I’ll take this a chief strategy officer role. And so, so far it’s working out pretty well. Yeah. I’m having a lot of fun and I want to, I don’t feel like I’m being put out to pasture.
[00:03:20] Bill Russell: [00:03:20] No it’s interesting because I do some coaching. And then when we talked with my friends who, and some of my friends who are younger and I’ll say there’s seasons of life, there’s a [00:03:30] season to be operational and run around and do a lot of stuff. And then there’s a season to be strategic those things, those things will change depending on the age of your kids, the experience that you have, the things that you do early on in your career. So you just look at them as seasons. This, this too shall pass.
[00:03:46] Dale Sanders: [00:03:46] Yeah. Yeah. And who knows, maybe I’ll get back into an operator role. I’m infatuated with our kids, with who you might hear running around in the background. You never know they may come barging into the office with no clothes on.
[00:03:58] Bill Russell: [00:03:58] Yeah, [00:04:00] well we going to do this interview back around Memorial day and so I had some questions. I see you have the flag in the background, but I am going to go back there cause it was, it was a moving post. And on Memorial day, you posted a picture of your father and it was our dad and brother served our mother cried. And it was a tribute to those families that lost loved ones in military service.
[00:04:23]Would you mind sharing about your dad and brother and their service and about that post?
[00:04:28]Dale Sanders: [00:04:28] Yeah. And I [00:04:30] might choke up a little bit here. So just be prepared for that. My dad was a veteran of world war II, Korea and Vietnam. Right. I mean, just imagine that. Just imagine the stress. Right. And before that he came out of the depression and the dust bowl and truly just the generation of grit that I can’t [00:05:00] even imagine. And he was a true Patriot. He was a great father to me and great father. I was youngest of six. So yeah, you just one of those guys that felt duty, bound and served in all three wars And finally retired in 1968. He w he retired from the strategic air command, which is kind of funny because that’s where I went back into the air force into the strategic air command.
[00:05:26] I kind of followed his footsteps and I’m really glad I did. And then [00:05:30] he retired in 68 so I was what nine years old at the time. And he was a gentleman farmer and rancher after that. And so it was a great time for me to spend time with him. I grew up roping cows and calves and branding and herding cows and doing all that right.
[00:05:50] And genuine cowboy with him. And then he passed away from you know, not directly from his military service, but he had [00:06:00] cardiovascular disease. But it was from all the stress and the smoking that went on during all that. So he died at 58, just a few days after I graduated from high school. So yeah, and my poor mom, I think he had his first heart attack when he was in his forties.
[00:06:17] And so my mom, now I can look back on it what that did to her, right. Worrying about her husband’s health and stress with six kids. And I can appreciate all [00:06:30] that hardship now more than, more than ever. But yeah and then my, brother followed my dad’s footsteps in the air force too, and a really sad story.
[00:06:40] He was killed in an accident along with two other people up at Elmendorf air force base. They were, they were turning a sority around, they were turning an aircraft around for a sority.. And the over pressurized the oxygen system on this plane and it blew up and [00:07:00] caused a fire and killed him and a couple of other guys.
[00:07:02] And so that was just devastating to my mom. Of course she alot. That was the second child that she’d lost was my brother. She lost, we lost a daughter before I was born at 18 months. So my poor mom just had, she was, oh my gosh. I just can’t even imagine the hardships she went through.
[00:07:21] Bill Russell: [00:07:21] Yeah. As a, as a parent, I’m sure it has a different meaning looking back now. And I want to, I want to thank you and your [00:07:30] family for the commitment and the service, but I want you to talk a little bit about your service. You did go the military route. And that really was a training ground for a lot of the stuff you have done since then. So talk a little bit about that.
[00:07:44]Dale Sanders: [00:07:44] Yeah, I mean, it was just a, an invaluable experience. I joined the air force in 83 after I graduated graduated the chemistry biology philosophy degree from a liberal arts school in Durango, Colorado. [00:08:00] Yeah. And just randomly, I really had no plans of going into the air force, even though I had that precedence in the family, but I randomly ran across this recruiter and he rattled off all the different options for me I wore glasses, so I couldn’t be a pilot and I was color blind too so that was out of the question, but he said we’ve got this new career field that we’re starting, that’s called information systems, engineer. And I was like, oh yeah, what’s that? And he said I’m not quite sure either, but I think it’s really [00:08:30] connect telephones and computers. And that was literally the conversation I had with him.
[00:08:34] I thought, huh. I bet there’s going to be a future in that. And literally I said, well let’s try it out. I’ll apply. So I applied and the application process was actually harder than I expected. I was accepted into officer’s candidate school. And then after that was four months of OCS and then another year of technical training around this information systems engineering program.
[00:09:00] [00:09:00] And then I thought, well, this was in the Reagan years, right? And the strategic defense initiative, we’re just kicking off and lots of emphasis around nuclear warfare and anti-ballistic missile defense and all that kind of thing. I thought, well, If I want to be in the thick of information systems, I’m going to go to the strategic air command. And so I did, and it was just phenomenal. It was just a mind blowing experience when you’re in your twenties and thirties, the [00:09:30] responsibilities they put on you.
[00:09:31]Bill Russell: [00:09:31] Yeah. It is. As I’m listening to that story, were you working a lot in cybersecurity at that point? Or was cyber security sort of out there still? Not, not, not too much of a concern?
[00:09:41] Dale Sanders: [00:09:41] Well, it was, I would, it was sort of embedded cyber security. Like it was sort of a natural part of your job with cybersecurity. But it wasn’t the same flavor of cybersecurity that we have today, right with an internet connected world. But information security at that time, InfoSec was just a natural part of your upbringing.
[00:09:59]Bill Russell: [00:09:59] Talk about [00:10:00] hiring people from the military. I would assume you think it’s a good idea. I mean, they’re given such a responsibility at such a young age. You can’t get that experience anywhere else right
[00:10:10] Dale Sanders: [00:10:10] No you can’t replicate it. You just can’t. And frankly, healthcare has always been a little boring because of that. Right. The bar of accountability and responsibility was set so high. Healthcare has always been just a little less satisfying for me. I’ve always had to find sort of adrenaline elsewhere outside of healthcare [00:10:30] with various adventures and things. Yeah.
[00:10:33] Bill Russell: [00:10:33] Well, we’re, we’re going to, in your, in your time off, I’ve been following some of your posts and whatnot, and people want us want us to talk about the things of the day and I’m just going to stroll through your posts.
[00:10:48] Cause I think some of them are pretty interesting. So the first one is I’ve been advocating that we should shift our us quality measures strategy from what it is now to a process oriented focus. Forcing clinicians to [00:11:00] enter data in the HR that proves they are following clinical process, which are proxies for outcomes.
[00:11:06] I would argue that we could, we should shift to a quality measure strategy that is focused on the elimination of low value care. Measuring what clinicians didn’t do, which is the absence of data and does not require data entry. Makes sense. There’s $300 billion per year wasted in LVC. And shifting our focus to that also saves [00:11:30] clinical data entry burden.
[00:11:31] This is a, this is a passion of yours. You’ve talked about this a fair number of times. What was the response to that post. What are you really trying to communicate? What’s the core of this.
[00:11:41] Dale Sanders: [00:11:41] Well, our quality measure strategy in the US isn’t working. Even, even some of the early pioneers who advocated measurement of quality like Don Berwick and Brad James are clearly saying it’s not working.
[00:11:55] It’s not changing the cost quality curve. Right. So for heaven [00:12:00] sakes, if our quality measure strategy is not working and there’s plenty of evidence that all this data entry burden that we put on clinicians to prove that they’re practicing, according those quality measures is burning them out. Why don’t we pause the train?
[00:12:14] Right. Let’s pause the train and take another look at this. Right? And there’s so there’s that body of evidence? Well, then there’s, there’s been this body of evidence around low value care that’s been around for at least a decade, probably 15 or 20 years [00:12:30] that if we stopped doing just a handful of unnecessary things in healthcare meds, orders, labs, we save all sorts of money. We reduce patient harm and inconvenience. And reduce the clinician data entry burden. And this is I think something that people don’t quite grasp. It’s the absence of data. It’s the absence of an order for preoperative labs. It’s the absence of an order for opioids for back pain [00:13:00] that proves that you’re, you’re not practicing low-value care.
[00:13:04] So it’s actually the absence of data entry. So when I made that post, there were a couple of people said, well, how do you prove something that didn’t happen? Right. Well, if the proof is in the absence of data. Whereas our current quality measures is all about documenting, documenting, documenting, proving in some way, justifying in some way that what you’re doing is practicing according to the quality measure strategy we have in the country now.
[00:13:30] [00:13:30] Low value care is the opposite of that. It’s the absence of data. It’s the absence of data entry.
[00:13:35]Bill Russell: [00:13:35] Where does this reside? Is this a CMS ONC?
[00:13:39]Dale Sanders: [00:13:39] Yeah, absolutely. It’s this is absolutely within the purview of CMS to do something about it. Now, the private payers, the private payers play a role too. But CMS as the largest purchaser of government services in the world or healthcare services in the world.
[00:13:56] CMS needs to lead this and they need to be proactive and [00:14:00] aggressive about it. And they got meaningful measures 2.0 that they’re working on right now, there was actually quite a bit of momentum around this in the Trump administration. And now I’ve noticed that there’s been a decline in momentum with the transition to the Biden administration on this notion of reducing the burden of EHR data entry on clinicians and kind of rethinking quality measures.
[00:14:25] So that’s why John Lee and I from Allegheny, Dr. John Lee and I have been on this road show [00:14:30] about this topic for, oh, I don’t know, a year, at least. And we’re going to keep going on the road show. And then hopefully I’ve got a, to do list here to start engaging more with some congressional staff about this topic too. We’ll work it from the top down.
[00:14:46] Bill Russell: [00:14:46] That’s interesting. I don’t imagine you would get much pushback from physicians. I would think they would be cheering you on in this.
[00:14:54] Dale Sanders: [00:14:54] I have yet, I would say 99 in [00:15:00] favor, maybe one opposed. And the occasional voice of opposition comes from clinicians who think that the definition of low value care is going to be hard for them to follow. Like the sort of the conversation thread sort of implies more pre-authorization. There’s all sorts of papers published about it. If you stopped doing these handful of things we say all [00:15:30] sorts of money and we prevent all sorts of patient harm and convenience. Now I’ll tell you one thing though. It’s also top-line revenue. Most of these, there’s two things that I think stand in the way of adopting low value.
[00:15:44] It generates top-line revenue for healthcare systems when you stopped doing these unnecessary meds and procedures. The other thing is clinicians will have to face this down and sometimes the best answer to a patient is no, not yes. [00:16:00] And what I mean by that. If I go in and I’ve got a runny nose and green mucus, and I’m asking for an antibiotic. We want an antibiotic, right? That’s what we expect as patient, but it’s up to that physician to say no and say, you know what, this is not good for you. It’s not good for society. I’m not going to prescribe an antibiotic for you.
[00:16:22] Bill Russell: [00:16:22] Yeah. That’s, that’s hard to do because that doesn’t that potentially hurt your scores, your customer satisfaction scores?
[00:16:28] Dale Sanders: [00:16:28] Potentially yeah. But [00:16:30] I think if you engage with most patients in a rational empathetic way to explain to them why I think most patients will trust their physicians. Right. I think most patients have an inherent trust in their physician.
[00:16:43] Bill Russell: [00:16:43] So you, you read a lot. I mean, during the pandemic, it was hard to keep up with all the posts that you were putting out there and all those studies that you were reading and commenting on. But this one was interesting, smart health and smart agriculture and fascinating parallel. Have you [00:17:00] taken up farming and what parallels are there?
[00:17:04] Dale Sanders: [00:17:04] Wow, that’s a fun project. So I’ve had a long relationship with Canadian healthcare and in particular in Alberta and the Alberta government asked me to come in and serve as their senior data strategist, basically exploring the hypothesis that the government should play a role in creating a data infrastructure that benefits, multiple industry segments. [00:17:30] So kind of borrowing from telecommunications and highways and railroads and water and sewer and power. Right? All those things that the government de-risked for private industry to build out infrastructure that supports multiple industry segments. Right? So the hypothesis is, should we be doing the same thing in the information age, around a data infrastructure?
[00:17:53] And so the two sort of the top two industry segments that we’re using to explore that hypothesis are [00:18:00] healthcare and agriculture. And yeah, it’s fun. Right? So I’ve got a little bit of a farming ranching background. So I’ve always enjoyed hanging out with farmers and ranchers and I’ve got a biology undergrad, so I can hang out in those conversations about growing things.
[00:18:17] And then I’m a data guy, so it’s fun. I’m having a blast. And I hope to finish that report sometime in September.
[00:18:26]Bill Russell: [00:18:26] I was talking to somebody agriculture and they were talking about how [00:18:30] I think it’s John Deere. I’m pretty sure it’s John Deere has changed their business model to be more of a platform company, a data services company. And they now have so much information on what crops were, how effective, how much, and it’s going to be.
[00:18:45] I mean, they literally are a phenomenal, one of the largest sources for information on exactly how we’re doing from an agriculture standpoint and how much we’re producing.
[00:18:56] Dale Sanders: [00:18:56] Yeah. It’s so cool to hang out with all of those. [00:19:00] I wrote that blog with these fascinating parallels between health care data and well, more like physicians and farmers. And there’s all these very interesting parallels when I stepped back to think about it. Like one of the parallels was the private farmer and the private physician are both kind of being squeezed out by corporate farming and corporate medicine. Right. One of the ironic sort of discongruent overlaps [00:19:30] between the two is that farmers are genuinely interested in the elimination of disease.
[00:19:37] I mean, it’s profitable for them to eliminate disease for their crops and livestock. It’s highly profitable for them to eliminate disease. Whereas in healthcare we make money off of disease. And so it’s a little weird. We we profit from disease in healthcare. We profit from from health and agriculture.
[00:19:57] And it’s fun to work between those two worlds. [00:20:00] But yeah. Going back to your question, I mean, John Deere is just one of many there’s a lot of data in smart agriculture and the cool thing about it too, is there’s not, there’s not These weird cultural oppositions to sharing data. There’s not this in healthcare, we’ve got HIPAA course that sort of transcends data sharing issues and things like that.
[00:20:28] But [00:20:30] there just isn’t this cultural momentum against data sharing in agriculture. Like there is in healthcare, like right nobody’s holding on to data in agriculture yet in a way, like I see healthcare systems holding onto their data and not sharing it in the U S market.
[00:20:48] Bill Russell: [00:20:48] I was going to ask you about your Bitcoin posts, which was pretty interesting, but I’m going to go to, I’m going to go to something different.
[00:20:54] So David Brailer was interviewed First national coordinator of health IT. [00:21:00] He was interviewed at CHIME by Scott McLean from MedStar. He had a lot of interesting comments and I want to, so here’s, and it’s in my post today on LinkedIn and he had this to say on public health, I came into the government not long after 9/11, when the L E X S the law enforcement exchange system was put in place to allow information sharing from local police department to the intelligence agencies.
[00:21:26] And I’m commenting on this because of your comment about. [00:21:30] And also, I want to talk about public health a little bit, and he goes on to say, so it was seamless and integrated and analyzed. And that was a perfect metaphor for the four public health P H X S is what they wanted to build for public health.
[00:21:45] And we designed that and we could never get it funded. And to this day, we’re living with a really dilapidated and obsolete public health information infrastructure. And he talks about during the pandemic. One of the states had to upgrade their MS Dos in order to get [00:22:00] access to something. And, and I was like, wow, I can’t even imagine. I mean, our health system had some old systems, but that, that would take the cake.
[00:22:09] Dale Sanders: [00:22:09] No doubt. That’s interesting. So I haven’t heard that story from him before, but I liked those parallels. Yeah. Yeah. That’s a really interesting point. After nine 11, we really did open up the interoperability of data between local law enforcement and national intelligence. Yeah.
[00:22:30] [00:22:30] Bill Russell: [00:22:30] So how do we do that? I mean, you’re heavily into data. You’ve done a lot of this. You’ve worked with governments and whatnot. So how do we do this in a way that it’s a privacy issue, right? So we want to protect privacy. There’s a general belief that you can re identify any de-identified data.
[00:22:47] And so we’re worried about that. There’s new paradigms coming up where we’re separating the algorithms from the actual data store so that we can, that we can protect the data in those ways. I mean, what, what, [00:23:00] what is the, what is the concern? Is it just a finance is the reason this isn’t right because of financial or is it privacy?
[00:23:09] Dale Sanders: [00:23:09] I think that we, I think the bottom line is, I think we overplay the privacy. And I ran a survey actually, when I was at Northwestern and we were just rolling out a portal for patients at that time. This was 15 years ago and we were wondering what, if it gets [00:23:30] hacked and what’s going to happen.
[00:23:32] And I ran a survey about patients’ concern over their healthcare data being hacked. And the concern was actually quite low. And if you look at how many times healthcare data has been compromised on a grand scale in US and yet patients’ reactions to that is actually quite low, right?
[00:23:55] Think about all the different payers and healthcare systems have been hacked [00:24:00] and all the healthcare data that’s been exposed, the public’s reaction to that is actually fairly muted. So I think, I think we overplay the privacy risk boogeyman. And the other thing that, you know, and I’ll lean on my NSA days, where we were doing quantitative risk analysis in all sorts of different settings.
[00:24:19]A bad event, like privacy being compromised depends on three basic things. Motivation of the perpetrator skills of the perpetrator [00:24:30] and access. To the data now, every fault tree that I ever created, every event tree that I ever created it and say came down to those three inputs to the top gate.
[00:24:41] Right. And, and when you, when you really do a quantitative analysis on access skills, motivation to do something bad with healthcare data it’s actually pretty small now on the black market. Medical records are pretty [00:25:00] important for identity theft and all that kind of thing. They pay a premium for that kind of thing.
[00:25:04] The credit card data is almost meaningless now because the credit card companies have taken care of that financial data is actually quite easy now to protect. So I would hope that going forward, we start thinking about real versus procedural. The perceived risk around privacy is a lot higher than the real risk number one. And number two, if, and when there’s a compromise, we can work faster to mitigate it just like the credit card companies have.
[00:25:31] [00:25:30] Bill Russell: [00:25:31] So national patient ID. Where do you stand on that whole conversation?
[00:25:37] Dale Sanders: [00:25:37] Well, we’ve got to have one. It’s just it’s again, the bogeyman of big government monitoring and all that right. To get a national ID. I mean, come on. That is a very vocal minority of people that oppose a national patient identifier. Most patients, most patients, especially if they knew the benefit, it would have to them would say, absolutely, sign me up. Let me have [00:26:00] a national patient identifier.
[00:26:01] Bill Russell: [00:26:01] So, so what is the benefit?
[00:26:04] Dale Sanders: [00:26:04] Well, it’s, it’s the ability to integrate records consistently going back to the public health and population health, sort of in the care delivery network. I’ll give you a great example. If we had a national patient identifier, it might be possible. It would be enabling that where I got my vaccine would actually show up in my medical record in Intermountain healthcare.
[00:26:30] [00:26:29] Right? So I’m part of Intermountain healthcare network here in Utah. EMR record has no indication of my vaccination. And so, right. And so fundamentally, if you don’t have a patient identifier that crosses over between where I got my vaccination and Intermountain healthcare, you can’t put Dale Sanders data in a repository right.
[00:26:55] Bill Russell: [00:26:55] Right. But there’s very little, you’re talking about two private, [00:27:00] well, one public probably and one private data system. What’s the incentive for them to pull that data together?
[00:27:07] Dale Sanders: [00:27:07] There isn’t one right now, Bill. That’s the problem, right? I mean it’s interesting to think about the incentives around law enforcement and exchanging records.
[00:27:17] There’s no financial incentive for them to do that either, but there’s a cultural incentive. There’s a cultural imperative and in healthcare there’s no, there’s still no great economic incentive for systems to share their name. [00:27:30] And for some reason, we haven’t reached the cultural tipping point like law enforcement and antiterrorism did. Maybe COVID will push us over the top. I don’t know. We’ll see.
[00:27:41]Bill Russell: [00:27:41] It’s interesting cause I’ve not been a fan of national patient ID. And the reason is because I think the information should aggregate around the consumer. And we aggregate information around the consumer all the time.
[00:27:54] I request this date, I request this data, from each one of the systems that have been a part of, and at that point, [00:28:00] there’s a number of identifiers that already exist around. Right. I mean, you can just look at my address, my phone number, my name, and those kinds of things. And you can say, this is probably this person with a very high degree of accuracy.
[00:28:15] Now I understand where that falls down. We have you know six addresses and a lot of health systems for different people. And and a good 6% of our patients in Southern California gave us incorrect social security numbers. [00:28:30] They probably were not potentially not legally in the country and those kinds of things, but we still provide them care.
[00:28:35] And so it was hard to match the record and without data, it’s hard to match the record period. So.
[00:28:43] Dale Sanders: [00:28:43] Well and it’s hard to do longitudinal health analysis. If you don’t have the ability to link my data over time. Right? I mean, all of us should have some sort of longitudinal view and trajectory of our health. And it’s very hard to do that. As an [00:29:00] analytics guy. I can talk all about that. How hard it is. To pull data from disparate systems about Dale Sanders. If you don’t have a common identifier, why or do you not support a national patient identifier? What do you, is it just the base you think?
[00:29:16] Bill Russell: [00:29:16] Because first of all, I think there should be joint custody of the record, right? The record today is owned by the health system. And I think there, I don’t, I don’t think they shouldn’t own it. They do. And I understand that. They created the record, but I [00:29:30] should have joint custody because it adds so much value to my life.
[00:29:33] Dale Sanders: [00:29:33] Absolutely.
[00:29:34] Bill Russell: [00:29:34] And so somebody with joint custody, I’m looking to big tech or somebody else to come along and give me a tool where I can make the request and gather all the information.
[00:29:44] Then I think what’s going to happen is we’re going to have an ecosystem of players that starts to get created around that. And it could be Intermountain who comes around and says, look, you’ve collected all that data. Not only from there, but also social determinants data, also data around your [00:30:00] groceries, your dives, that you’ve done the steps and all that other stuff.
[00:30:03] And what I want is I want to create that system, that ecosystem as quickly as possible. And I think it has to be done around the consumer. Where there’s an incentive for people to take all my information, see my whole profile and say, all right. Yes, we are going to help you to live a healthier life.
[00:30:20] Because quite frankly, if I want, if I’m really sick, I’m going to mail. And if I’m if I’m moderately sick [00:30:30] I’m going down the street. And if I don’t know what I have, I’m just going to go tell him. And there’s not much differentiation for me, but if somebody is going to finally come alongside me and say, look, I don’t just want your sick care dollars.
[00:30:42] I want to make sure that you stay healthy. I want to make sure that I take off the COVID 15 and I want to make sure. You understand that your father had these conditions and they have this impact on you. And those kind of things, because my dad had heart issues pretty early on in his life and I’m actually [00:31:00] past the age of his first heart attack. So I worry about such things. But my health system in this, has my, has all these records and no one’s looking at it today cause I’m not there.
[00:31:11] Dale Sanders: [00:31:11] Hmm. Interesting. Yeah.
[00:31:14] Bill Russell: [00:31:14] I want to find somebody who’s going to actively participate in my health. And I, I don’t think that’s, I don’t see the health systems running in that direction because again, the financial incentives aren’t there. So that’s why I’d like to see this system graded outside of it.
[00:31:27] Dale Sanders: [00:31:27] I like it. Interesting thought. I like it. [00:31:30] Yeah.
[00:31:31]Bill Russell: [00:31:31] I want to talk a little bit about your future here. So you, you went over to IMO. Tell us a little bit about IMO and what you’re going to be doing there. Strategy. I know but.
[00:31:40] Dale Sanders: [00:31:40] Strategy that’s right. Well I was one of IMOs first customers back at Northwestern and it was around clinician friendly terms at the front end of the EHR at that time. Clinician did dissatisfaction with the HRS was so high. It was like anything that I [00:32:00] can do to make a little more comfortable with epic concern, or at that time, I’m happy to spend some money on it.
[00:32:06] And clinicians preferred using the IMO terminology to manage their problems. Three to one over med and ICD and that kind of thing. So, yeah so, and I ran that AB test. And so I, for the money, it was clearly something that I wanted to do to add a little bit of life to a, or a little bit of satisfaction to the lives [00:32:30] of clinicians, with the EHR.
[00:32:32] The other thing I was doing at the time was building the enterprise data warehouse at Northwestern. So I wanted to carry those terms, those IMO terms that were more clinically precise, all the way through to analytics and the notion being that more clinically precise terms on the front end means more clinically precise analytics on the backend.
[00:32:55] And we made progress on that. We did a little bit of that at Northwestern, but then I moved down to the Cayman [00:33:00] islands, kind of left all of that behind. Went on to health catalyst, and it’s sort of an UN, unless it’s an unknown unsatisfied part of my life. I want to go back to that and deal with data quality and physician experience at the beginning of the data journey.
[00:33:20] So I’ve been sort of the analytics guy in healthcare for since 1997. And I’ve been struggling with data quality. In analytics ever [00:33:30] since cleaning up data. I mean, I mean the cleanup that you have to go through as an analytics company and an AI company is insane. And the truth is it’s a dog chasing its tail because you never really get ahead of the data quality problems.
[00:33:43] The problem with data quality starts at the beginning of the data stream. So what I hope I can do at IMO is a couple of things. I want to continue to leverage IMOs, clinician, friendly, experience personality around EHR. [00:34:00] Which means that I plan on advocating some, some new things that we’re going to do in the, in the EHR experience world with IMOs brand.
[00:34:13] And then downstream from that, recognizing that not all data is going to be standardized to national terms, international terms, we’ll always have a need for curation of data and normalization of data. So we’re building out tools to [00:34:30] speed up and accelerate the accuracy of normalizing disparate, DHR, and clinical and claims data, or kind of leapfrogging what’s out there in the industry right now with those normalizations.
[00:34:41] And then downstream of that, I want to take a run at making value sets more meaningful and useful. We were off track as a country, I believe with the value set of 30 center. No criticisms of the people. I love the people there, but the strategy, the value set authorities, the center has never really [00:35:00] reached what we had hoped.
[00:35:01] It would be way back in 2008, 2009, when we were kicking it off. So value sets is another area that we’re going to play a big part in with IMO. Again, maintaining that IMO terminology throughout the lifespan of the data. Also and I don’t know that everybody understands this, but I am Moe has a proprietary terminology, but it maps to all national and international standards in the back end.
[00:35:26] So you get the, you get the best of clinically friendly, clinically [00:35:30] precise terms with all of the national and international mappings in the back. So it’s, it’s basically addressing these data quality problems that are driving me crazy as an analytics guy. I want to get upstream of it to the clinician experience, to the data quality curation pipeline.
[00:35:48] Bill Russell: [00:35:48] Yeah, it is. And it’s amazing how much money and effort goes into that piece. And we want it to go downstream a little bit. In doing research for our conversation, I came [00:36:00] across a study that IMO and HIMSS did with, it was a survey of clinical business and it personnel various us hospitals, and they were looking to understand how patient data is being used in decision-making analytics and how challenges with data quality are getting in the way of achieving enterprise goals.
[00:36:20] And the research was interesting. 57% reported that data is inconsistent due to subjective documentation from providers. There’s no [00:36:30] surprise there. I guess 50% said that the data derived or extracted from external search sources is variable in accuracy and completeness. And despite these issues and others organizations are using patient data for a range of initiatives, including quality measurement and reporting 81% revenue cycle management, 60% in clinical decision support, 55% this data quality is an issue every time we, you and I get on the line, we end up talking about it. [00:37:00] There there is no silver bullet. I mean, you, you are going to be doing some things here and leapfrogging, but there there’s no silver bullet to that at the front end, the clinicians just going to go this is a perfect note. This is the perfect documentation. This is the perfect order.
[00:37:15] Dale Sanders: [00:37:15] Yeah. Well, that’s true, Bill. What I would say though, as a country, we need to mandate that orders, the results, as a minimum, orders and results have to be harmonized to national standards. [00:37:30] At Catalyst we built touchstone, which was this national repository of VHR data.
[00:37:35] And depending on how you slice the data at most 20% of lab results. Are harmonized to LOINC. So 80% of our lab results have no associated LOINC code with them. And for medications it’s even lower, it’s less than 1% harmonize to RX norm. And the analogy that I use for that is [00:38:00] imagine if you went to the grocery store or to target or Walmart or whatever else, and one out of 10, maybe one out of 50 products had a UPC code on it.
[00:38:14] What would be the implications to the consumer experience? What would be the implications to the supply chain, to the manufacturer? If retail products didn’t have UPC codes on them. So UPC codes are to retail what standard terms [00:38:30] are in healthcare and we have not embraced it and it’s ridiculous that we don’t. It should be a mandated law.
[00:38:36] Every lab order, every lab result, every medication order, every medication prescription should be associated with national and international standards. And that’s something that has zero impact on the clinician experience, by the way, that all happens in the background. When you set up your order rules, catalog, and the only reason that we’re we’re harmonizing to anything right now is if it’s associated with reimbursement, [00:39:00] that’s why the numbers are so low.
[00:39:03] Bill Russell: [00:39:03] So if you’re sitting in the CIO chair. I just hired you to be my CIO for the health system. What are you doing to get ahead of this? I mean, are there some, some there’s some basic blocking and tackling that is pretty, pretty easy to, to get done?
[00:39:16] Dale Sanders: [00:39:16] Well fundamentally when you deploy your EHR, we should have all built orderable catalogs that were harmonized to national standards. All right. Very few if any organizations did that. Now we’ve got to [00:39:30] go back and retrofit them. So I would kick off an initiative and say, look, we’re going to lead the way with this and we’re going to chip away so that every one of our orderables has a national standard term associated with it. Even if it doesn’t have anything to do with reimbursement, everything we order is going to have a UPC code associated with it.
[00:39:52] And by the way, I’ll comment on this too, Bill. Going back to the military for a second. I was weaned from military commanders who [00:40:00] insisted on data quality. All right. It wasn’t a nice to have, it was like goddammit Lieutenant, make sure this data is accurate and don’t come back until it is.
[00:40:12] And by the way, if we need to build more satellites and sensors to make this data better, then let’s go kick off for procurement to do. So there’s, there’s an insistence at the leadership level of the military, around data and data quality and data analysis that does not exist on our healthcare executive [00:40:30] culture.
[00:40:30] Now it’s that kind of insistence around being informed for decision making that’s missing in the leadership of healthcare right now. And I don’t think healthcare executives ever really get exposed to how poor the data quality is that they think they’re, that they think is high quality and the decisions that they make are so off base.
[00:40:49]Bill Russell: [00:40:49] They ask for reports, we give them reports and we’ve cleaned it all up and we put it in front of them. They go, oh, they can tell us within, but, but we know from, [00:41:00] well, I mean, this is sort of an interesting one but we know from IBM Watson that the quality of the data was not good enough to train AI models and we’re seeing over and over again. That same challenge.
[00:41:14] Dale Sanders: [00:41:14] There’s a great paper, by the way, on data quality that Google wrote in March, I highly recommend everyone. I’ve got it out. I’ve published it on social media a couple of times. It’s called everybody wants to do the models. Nobody wants to do data quality. [00:41:30] And so here you have Google, arguably the most sophisticated AI culture in the world. Who could easily over-hype AI saying AI is underperforming across a number of sectors, especially healthcare, because the data quality is so poor. Everybody wants to be a data scientist.
[00:41:49] Nobody wants to be a data normalization and data engineer on the front end.
[00:41:55] Bill Russell: [00:41:55] Not, not looking at Mayo or HCA, but looking at the agreement [00:42:00] that Ascension did with Google. Think about the data. I mean, just the data aspect of this. So essentially what essentially said is, look, we’re not going to do the big EHR implementation to get to a single standard because they have a hundred hospitals and literally like 70 or 80 EHR is out there, whatever the number is.
[00:42:19] And so they said, all right, here’s what we’re gonna do. We’re gonna find the premier data company in the world and we’re going to partner with them. So they partner with Google. All the data goes there. They create a [00:42:30] clinical interface of some kind that integrates into the EHR, no matter what it is, where they can do have a different interface to pull together all the longitudinal record and to search it just like you would search Google and a bunch of other things like that.
[00:42:45] I’ve seen the video on it. It’s really fascinating. And it’s, it’s, it’s really kind of compelling when you see it. But that’s really hard to do. Isn’t it? I mean, they had to essentially the microcosm of what we were just describing, they had to [00:43:00] do across 80 or 100 hospitals and saw that data and had to figure out how are we going to bring all this stuff together?
[00:43:07] Dale Sanders: [00:43:07] Well the truth is it’s not as hard as everybody thinks it is. And we basically did that in Health Catalyst. So wherever there’s a data operating system from Health Catalyst installed. That disparate EHR data is being peeled out of those EHRs and put into the data operating system. And then over the top of that is a care management skin.
[00:43:28] A web app and [00:43:30] mobile app that looks at that data from a patient across the continuum. So really skinny. Healthcare data is not that hard, really Bill. So I do think the app that Google put together was cool, but the truth is Health Catalyst did it quite a while ago. And it’s not that hard to do once you peel the data out of those systems, put it in a nice modern infrastructure with the software tools we have now today. I mean, it makes it super easy to re-skin that data and, and make it a lot more [00:44:00] user-friendly.
[00:44:00] Bill Russell: [00:44:00] You just have to keep the the source data to reference, I would assume at any given time. And you’re using tons of metadata. I would imagine around the data.
[00:44:13]Dale Sanders: [00:44:13] It depends on how you define the metadata.
[00:44:16] Bill Russell: [00:44:16] Well, I mean, if you’re going to be, whenever I hear re-skinning and all those kinds of things, I remember the conversations I was having with physicians how do I know where this, this data originated from? How do I know Just all the [00:44:30] information around the data itself, but they want to know is this patient generated? Is it physician generated? And so anytime you re-skin, it they’re going to go all what where to come from? What was the context?
[00:44:43] Dale Sanders: [00:44:43] Yeah. Well, I can’t claim that we did that. And I, and I don’t know. I don’t recall seeing that in the Google app. But you have a good point. It’s a good point.
[00:44:53] Bill Russell: [00:44:53] I’m not sure if they’re either. I was just sort of, it’s just interesting to me that, that whole thing. Listen, let’s talk a little bit about the [00:45:00] pandemic. We’re not through yet. I think we’re approaching 70% people vaccinated, something to that. I don’t know what the exact number is.
[00:45:07] I know there was a target of 75 by the 4th of July and I don’t think we’re going to hit that, but it really is kind of amazing. We look at it and we there’s so many fingers pointing, but it’s really kind of an amazing accomplishment that 14, 15 months after we identified something that we have 70% of the people vaccinated in the United States. We have a vaccine.
[00:45:29] We have multiple [00:45:30] vaccines. I, I think sometimes we don’t recognize how amazing it is, where we’re at, because we’re too busy trying to politicize the whole thing. It is pretty amazing. Isn’t it?
[00:45:40] Dale Sanders: [00:45:40] Oh, it’s mind blowing. Right. And it’s very interesting for me. The juxtaposition between how amazing the vaccination process went versus the situational awareness of what’s going on with COVID.
[00:45:54] Who’s got it. Where are the outbreaks happening? How many patients do we need? What’s our ability to manage this [00:46:00] from a capacity capably, like right. We were off the charts, terrible at situational awareness. Right. And you think about all the thousands of beds that, that we put in exhibit halls in anticipation of overwhelming numbers.
[00:46:15] We just had no clue about the situational awareness and the rate of infection and all that kind of thing with COVID. Terrible at that stuff. Right. The vaccinations like it’s mind-blowing, I mean, it’s, it is truly admirable. [00:46:30] And I, and I it speaks to the power of the country and I think we all should be kind of humbled at the scientists and the engineers and the logistics that went into the vaccination.
[00:46:42] It’s fascinating. And I just saw the other day. Now we’ve got CRISPR and messenger RNA technology kind of coming together with the first vaccination of its type to treat a genetic disorder. So yeah COVID for all of this terrible tragedy [00:47:00] is kind of, I think it’s going to have a big, positive impact on society.
[00:47:05] Bill Russell: [00:47:05] Yeah, it’s it’s I remember I was talking to a guy early on in the pandemic. I was talking to him about a vaccine and he goes, you shouldn’t expect a vaccine for another two years. He goes, and that’s quick. He goes, typically what we’re talking about is three to four years for this, for something you’re going to roll out on this level.
[00:47:23] I’m like, it’s amazing. I’m like, are you kidding? Dr. Klasko did this thing pandemic 2030, and he, as [00:47:30] he’s prone to do, we already create a slide deck of, Here’s how we’re going to experience it in 2030. And he sort of, he paints pictures and I like that from leaders. I like when they paint pictures that we can follow.
[00:47:41]But you pointed out, I remember following your posts early on in the year, there was a lot of confusion can we get COVID from cardboard boxes from Amazon that we’re receiving? Can we how does it spread? And those kind of things, there was a lot of confusion. What would you like to see?
[00:48:00] [00:47:59] What do you think needs to be in place before 2030? Hopefully 2030 won’t be the next pandemic, but let’s assume it is. What would you like to see in place from your world perspective, from your data perspective?
[00:48:13] Dale Sanders: [00:48:13] Yeah, so good question. And I’ve come into this advocacy for a data strategist and it’s, it’s a new sort of skill. I think that we all need to recognize. I didn’t really appreciate the value of it until I [00:48:30] was participating in some of these things. COVID national forums where people were just not thinking about data strategy at the level that I thought we should. So, if you would step back and say, as a data strategist, what do we need to do?
[00:48:45] What have we learned about from COVID that we need to apply going forward? There are a couple of things right off the top of my head, and that is this distinction we make between public health and population health, infectious disease [00:49:00] and chronic disease. We’ve got to stop that. Right. So not only is it a cultural barrier that should not exist.
[00:49:06] And by the way, in other foreign countries it does not exist. The separation between public health and population health that we see in the US does not exist in other countries. So culturally, those two worlds have to work better together than they do right now. And then stepping back, we have to say, what’s the data strategy to tie those two worlds together, right?
[00:49:28] Because if you think about COVID, for [00:49:30] example, COVID is an infectious disease. That’s the world of public health but go tell those nurses and doctors and the health care facilities that that’s a public health issue. That was absolutely a population health issue that overwhelmed our clinicians. Right? So this distinction that we make between public and population health has to stop.
[00:49:50] And then beneath that is, is the data strategy that ties those two worlds together. So that we’re sharing data between the two and coming back to [00:50:00] standard sort of classic decision theory, which comes down to situational where. Hypothesis generation about the situation and then interventions and assessment, right?
[00:50:12] Once you generate a hypothesis, you intervene, you do something you step back and you look at it. That’s classic decision theory, right? So taking a data strategist approach. That brings those two worlds together and a decision theory approach to the data that we need to support [00:50:30] those three components of decision making is I think fundamentally important to the future.
[00:50:36]Bill Russell: [00:50:36] Dale, I want to I want to thank you. I always like sitting down with you and I look forward to sitting down with you more in your chief strategy role. Are you going to be at any of the upcoming events that are on the calendar? HIMSS, HLTH any of those conferences?
[00:50:53] Dale Sanders: [00:50:53] Yeah IMO, marketing team tells me I have to go to HIMSS. So, so I’m going to HIMSS [00:51:00] and I’m doing a little bit of traveling, but you know, I’m never going to go back to traveling like I was at that Health Catalyst. I there’s just no need for it. And again, falling back to my priority in life right now is those kids. I’m never going back to traveling like I did.
[00:51:14] Bill Russell: [00:51:14] No. And I understand that completely. I’m sort of struggling to go back to traveling at all, to be honest with you, because this is, this is pretty nice to have dinner with the family every night and see everybody and still get to interact with your peers and have conversations
[00:51:30] [00:51:30] Dale Sanders: [00:51:30] Yeah, totally. I mean, I think I’ve had more one-on-one personal conversations in the last year and a half than I ever have in my life. Thanks to zoom and teams and everything else for that.
[00:51:42] Bill Russell: [00:51:42] There there’s a lot of waste in travel isn’t there.
[00:51:45] Dale Sanders: [00:51:45] Oh, totally.
[00:51:46] Bill Russell: [00:51:46] Dale, great catching up with you. Thanks. Thanks again for your time.
[00:51:48] Appreciate it.
[00:51:49] Dale Sanders: [00:51:49] Yeah, sure. Bill. Thank you. Keep doing good work. Appreciate you.
[00:51:53]Bill Russell: [00:51:53] What a great discussion. If you know someone that might benefit from our channel, from these kinds of discussions, please forward them a note, [00:52:00] perhaps your team, your staff. I know if I were a CIO today, I would have every one of my team members listening to this show. It’s conference level value every week. They can subscribe on our website thisweekhealth.com or they can go wherever you listen to podcasts, Apple, Google, Overcast, which is what I use, Spotify, Stitcher. You name it. We’re out there. They can find us. Go ahead. Subscribe today. Send a note to someone and have them subscribe as well. We want to thank our channel sponsors who are investing in our mission to develop the next generation of health [00:52:30] IT leaders. Those are VMware, Hill-Rom, StarBridge Advisers, Aruba and McAfee. Thanks for listening. That’s all for now.