May 12, 2020

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May 12, 2020: For this special edition of Tuesday News Day Bill is joined by Drex to deliver a two-part episode! After discussing the news, our hosts switch gears and share a section of their presentation of a business-centric IT approach to the reopening health systems. For the news segment, Bill and Drex use a white paper about contact tracing as a springboard to discuss the complexities of this issue, including how it works and the tradeoffs between its efficacy and the privacy issues it raises. The discussion moves to today’s second news piece arguing that health systems should restart now to map out safe safe back-to-work strategies, and our hosts talk about playbooks on the subject already being released by Atrium and UH. Next up, we dive into a listener question about when hospital revenue might return to pre-COVID levels. It might be a year or it might be never, but you’ll hear some positives for consumers either way. Moving onto the tail end of the show, we jump over to YouTube where Drex and Bill deliver their presentation segment, giving health systems seven action points for reopening. These include suggestions to restart the economy, restore trust, recapture lost revenue, reduce cost structures, capture government dollars, take advantage of disruption, and adapt to capture new reimbursement dollars. Tune in for some great perspectives on contact tracing and what the procedure of opening back up again might look like.

Key Points From This Episode:

  • Drawbacks of digital contact tracing like privacy raised in the ‘Outpacing the Virus’ paper.
  • How contact tracing works and whether it’s effective if some people opt out of it.
  • The question of whether lost privacy liberties will be restored once the virus cools off.
  • Examples of worrying tracking measures implemented by governments.
  • Discussing an article on the need for health systems to map out safe back-to-work strategies.
  • Health systems are trusted thus must guide us; back to work guides by UH and Atrium.
  • Telemedicine breakthroughs and whether hospitals will return to pre-COVID revenue levels.
  • Revenue decreases and worries about small and mid-size health systems.
  • Action points from Bill and Drex for a business-centric IT approach to reopening.
  • Necessary measures to be taken to restart the economy/health system economy.
  • The need for health systems to guide people and end tattletale culture, thus restoring trust.
  • How health systems might figure out a way to recapture lost revenue; ramping capacity.
  • The use of modeling and the need for health systems to reduce their cost structure.
  • Telehealth grants and how health systems should begin capturing government dollars.
  • Strategic partnerships and how health systems can take advantage of disruption.
  • The need for health systems to adapt to capture reimbursement dollars.

News Day – Contract Tracing and Opening Playbook

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News Day – Contract Tracing and Opening Playbook

Episode 246: Transcript – May 12, 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.

[0:00:04.5] BR: Welcome to This Week in Health IT. It’s Tuesday News Day where we look at the news which will impact health IT. Today, Drex DeFord is in the house for a deep dive on contact tracing and a special extended edition only on YouTube. More on that in a moment. My name is Bill Russell, healthcare CIO coach and creator of This Week in Health IT a set of podcast, videos and collaboration events dedicated to developing the next generation of health leaders.

This episode and every episode since we started the COVID-19 series have been sponsored by Sirius healthcare. They reached out to me to see how we might partner during this time and that is how we’ve been able to support producing daily shows. Special thanks to Sirius for supporting the show’s efforts during the crisis.

I want to thank everyone who shot me a note last week, you’re helping to shape the show. To those who didn’t, just know that I want to hear from you so please shoot me a note. [email protected]. You know, just answer the question, what’s the biggest health IT question you have right now and you want us to – you either want me to talk to with a guest about or discuss in the show. Go ahead and send that over right now, I love hearing him. I did get a couple last week and I really appreciate it. 

Will Weeders sent me a nice note with some comments and Ed Marks sent me some comments and others and we’re going to touch on some of those things today. As I said, it’s Tuesday News Day, Drex DeFord is in the house to talk a little health IT news. How’s it going Drex?

[0:01:33.6] DD: Good. I love Will Weeders, isn’t he not one of like the smartest guys? I mean, I know he’s just down the road here and not to blow smoke up his skirt but I like on twitter, he’s a good insightful smart guy.

[0:01:47.6] BR: He is absolutely.

[0:01:47.9] DD: A good person, he’s just a good dude.

[0:01:50.0] BR: He is absolutely and his email was – anything he writes is really insightful. But my audience is not as familiar with him as they should be because he has not been on the show yet.

[0:02:06.2] DD: We got to fix that.

[0:02:06.3] BR: This is an open invitation to Will, as you’re listening to this, know that you have an open invitation, any time you want, we’ll jump on, we’ll talk, whatever you want, digital health, we’ll talk innovation, we’ll talk operations, whatever you want to talk health IT, open invitation.

[0:02:24.4] DD: Good, I like it.

[0:02:26.0] BR: All right. People don’t know this but you and I have done our first joint consulting project and it’s always fun to work together.

[0:02:33.9] DD: Yeah, absolutely.

[0:02:35.7] BR: You know, for us, a lot of our research is done right here on the show, we’ve done 50 plus episodes over the last eight weeks talking with all sorts of health systems, vendor partners and others and we put together a presentation based on what we’ve heard from the show and then we mapped it out, till we think it’s coming next in healthcare and health IT and I personally shared that deck with my coaching clients and we’ve given presentations to sales organizations and executives and we’re even going to talk to some product development teams  here shortly.

What we’re going to do today, a little different. Following the news segment, we’re going to share just one section of the presentation we did but it will only be at the end of the YouTube episode. The podcast will end as it usually does, as my people like to tell me five minutes over what it should be so at about 20, 25 minutes.

You know, it will continue on the YouTube channel so if you want to see that snippet of the presentation that Drex and I are doing, you’re going to have to go over to the YouTube channel, just scan through towards the end and the show is going to continue. While you’re there, we’re going to start doing some fun stuff on YouTube so we want everyone to subscribe so you don’t miss a minute of it.

Just go, head over there, click on subscribe and you will be connected in. All right, let’s get to the news, Drex, I love how smart you think I am, you send me a 32 page document, 90 minutes before the show and said “Hey, let’s cover this.” This is something you share on 3x Drex and that’s text Drex to 484848 and you get the – get those emails but so we’re going to go through this a little bit and we’re going to talk contact tracing.

The 32 page document is called Outpacing the Virus, Digital Response to Containing the Spread of COVID 19 While Mitigating Privacy Risks. He also send another – you send a couple other stories.

[0:04:28.8] DD: Yeah, there is a bunch of stuff. Bill and I were talking before we started recording and the only – mostly the email that I get at [email protected] is email for myself as I read tons of stuff over the course of a week, I start to see things that I think are like, this is an interesting pattern or that’s the thing I need to learn more about because I’m not – there’s just lots of stuff that – the more I know about things – as with all of us, the more we know about things, the more we realize we don’t know we understand about things.

Things like contact tracing which seems to be super important in the how are we going to really get over the hump and stay over the hump until we have a vaccine or some other way of helping us get to herd immunity, one of the really important parts of this is contact tracing which sounds sort of theoretically pretty simple until you get into it and then you realize, it’s actually really complicated. Like if I asked you, who have you seen in the last two weeks? Bill, who have you seen in the last two weeks if we were contact tracing you.

Now, maybe because you’ve been pretty much locked down, that would be a really small number. 

[0:05:40.7] BR: Yeah, it’s interesting, this has been put out there as one of the core tenants to a solution. Bipartisan and so everyone is saying contact tracing is a key part, we’ve seen it in south Korea work pretty effectively and Singapore I think or some other place, well China as well used it. But there’s a lot of challenges.

Let me tee up some of the stuff because I love the fact that you sent this over because I had the same thought of I don’t know enough about this topic and so you know, just reading this stuff is really helps me. Here’s the setup for it. The virus is novel which means there’s no current defense for this version. Unlike the flu where we have vaccines from year to year, this is novel. The virus has stealth transmission. Incubation period, 14 days, the lethality of the virus is believed to be many times higher than seasonal flu. The virus has a very high natural transmission rate.

Contact tracing, fully manual as you said, relies on a lot of workers to go through that information and it relies on my memory quite frankly. Some of the options for contact tracing are fully manual, encrypted peer to peer protocol based on something like Bluetooth and a location based protocol, these are just some of the things that are highlighted in this story. I’m just going to – a couple more bullet points and you and I are going to get into conversation.

Again, relies on human memory, manual contact tracing takes time, a lot of time, probably too much time. Either that or just tons of people so manual contact tracing.

[0:07:25.4] DD: Takes tons of people

[0:07:28.0] BR: You have to train and you just a lot of people. It’s been proven insufficient to contain COVID-19 on its own today. Up comes technology, you know, it’s more it’s more accurate, it’s fast, it’s low cost and it’s been proven to work. Taiwan, South Korea and other places which is you know, pretty exciting but then you get into some of the challenges with it so privacy. Before we get it to the privacy problem, let’s talk about how this would work.

Bluetooth, well, I don’t know about you but I don’t have Bluetooth turned on my phone most of the time. What are they proposing here?

[0:08:12.2] DD: Yeah, in theory, this is probably something that I’ll post on 3xDrex this week too – there’s actually cool little MIT video that sort of describes in about three minutes how this works but you would download an app and it would use sort of the capabilities of your phone through – and the Bluetooth capability to as you walk around and did things, if it saw other phones that had the app and the Bluetooth turned on, it would record that it had talked to that phone that it had been in contact with that phone and it would be able to say, I was in contact with that phone for like five minutes or 35 minutes or 20 seconds. 

You could build a protocol around that, that says, if you were only in contact with another phone for 20 seconds, maybe that’s not enough to notify you if somebody comes up positive but if you were there for three minutes or four minutes, maybe that’s enough. Then, basically, what happens is that your phone – it’s, you know, it’s a piece of data that’s de-identified, goes into a big master database and then if somebody comes up positive, they would say on their phone that they’ve come up positive for COVID 19. That would send a note to the database and the database would look for all the phones that have been in close contact to you and it would notify those phones, the owners of those phones, that somebody had been in contact with them probably around this date and probably for about this long.

That would then trigger what could be a lot of different responses including recommendation if it was above a particular threshold to get in touch with the public health person or public health person might actually try to reach out to you because of that. But you’re right, a lot of this gets into privacy, right? How much information do you disclose, how much information does your phone disclose?Do you want to walk around with these apps on your phone, would you use them if it’s optional? There’s a lot of people who won’t do it. If it’s optional, a lot of people who don’t do it, is it worth the effort? You know, is it sort of partially affective and I think those are the things that I’m kind of learning about and trying to figure out now too.

But there’s a lot – you know, like I said in the beginning, it feels like it’s probably a pretty simple thing but when you start to sit down and just work through a single scenario of me talking to you about who you’ve been in contact with for the last 14 days. We rely on you to tell me who all those people were including maybe a bunch of people that you didn’t know but you know that you did go to the grocery store on a particular day three days ago and  you were in the store for about this long so there’s a lot – now we start with a lot of  head scratching like who else was in the store like which checkout did you go through and did you touch – did you take a cart or you didn’t take a cart. 

There’s a lot of other things that kind of come into this. It gets confusing really fast and you talk to guys. I hear Mark Cuban on the air talking about things like maybe the human contact tracing program is a good way for the government to employ a bunch of people in the near term who are unemployed as contact tracers. That also gets back to, you have to have some particular kinds of skills and you have to be trained and you have to know how to ask questions and all of that. It’s not easy to just turn somebody on as a contact tracer either.

[0:11:43.2] BR: This is where Hollywood has done a good job of educating us on what the dystopian outcome could be, right? Total Recall or Terminator, Skynet, you know, this kind of stuff, the stuff starts with. This is where it gets complex, right? I like this article because – or white paper really. Because they talk about how much of the data actually stays on the phone, stays local, how it rotates the hashes so it is almost impossible to de-identify but they also talk about how law should come alongside of this and make it essentially a federal crime to even attempt to de-identify this data.

I mean, you have to protect the integrity of the people using this for the good of the community so that they don’t – I don’t know, get tracked for some other reason down the road and so that – this goes through that, it goes through hashing, storing locally. The centralized server, quite frankly needs a bunch of information that it doesn’t have in order to decrypt the location and the ID of the phone, those kind of things.

But, as you know, they sort of pieced this all back together, once you are COVID positive, it has a chain to go back and identify the people that you were around to give them the kind of warnings they need to know that they have been exposed. 

[0:13:23.4] DD: You know, I mean, the bottom line is, as hard as we can work to de-identify and make things very difficult to reassemble, there are people out there who are willing to work really hard to figure out how to undo the work that you’ve done to make things anonymous and de-identified.

You know, nothing is fool proof and some of this ultimately just comes down to what’s the right thing to do and there’s no solid, single answer for that either. What’s the right thing to do to try to cut the virus off at the pass and so yeah, to tell you it’s definitely a tough one. There’s also bills out there, you know, there’s a couple of bills that have been introduced about contact tracing and the data that’s gathered for contract tracing and what it can be used for, how long it can be retained and what the disposal and destruction process has to be for it and all of that. 

There are definitely people in congress too who are thinking about all of those issues. 

[0:14:26.6] BR: Well, it’s interesting because this article again doesn’t shy away from that, you get down closer to the bottom, page 26, starts talking about what groups like the ACLU have written and put together around this. Because during the H1N1, they actually approached this subject back then and let’s see, “Previously, ACLU literature on the individual rights in times of pandemics, particularly white papers written during the H1N1 outbreak focused on maintaining public trust and public health authorities and encouraging public cooperation and mitigate disease.” It just goes, it has that, it has in defense of a freedom out of time of crisis. It actually, it touches on the literature and there’s a fair amount of it that’s been written around – 

Okay, around the time of a pandemic, around the time of a crisis, what is the tradeoff? And does the tradeoff change for a period of time where it’s you know, we give up some of our personal liberties in order to protect the greater good and then as long as – I think a lot of us would do that as long as we were assured that it would bounce back. It would not be an indefinite kind of program where they’re tracking us all the time.

[0:15:49.5] DD: Right. I mean, we’ve seen examples of laws, regulations, rules that were created specifically after 9/11 that continue to this day that allows some pretty significant surveillance of the public and monitoring telephone conversations and other things that I think as also – those are the kinds of things that have put a lot of people in this position of saying, once you lose those liberties, you never really are able to get them back. Like the government’s never going to give – you know, there’s a lot of paranoia around it which I understand but I’m also with you that I would be willing to give up some liberties for the good of the group if I knew that everything bounced back after the fact. It’s just that part of it how do you know it bounces back after the fact?

[0:16:46.2] BR: You either have not watched any movies or you have no imagination if there isn’t a certain amount of skepticism on how this is going to be used. I mean, for instance, Thailand. You sent a couple of articles, that one, that white paper, I will include them in the link but the other one you send was technology, MIT technology review and they have a list of all the contact tracing programs that are out there. One of the examples was Thailand.

Thailand, National Broadcasting and Telecommunication Commissions provided a sim card to every foreigner – just think of that – every foreigner and Thai who has traveled from countries that have been designated as high risk for COVID 19 infections at the time. China, Hong Kong, South Korea, Italy, Macao, I thought Macao was part of China but I guess not. The app will track the phone’s location position for 14 days and alert authorities if they leave the designated quarantine area.

That’s what we’re afraid of, right?

[0:17:45.6] DD: Yeah, I mean, that’s like an ankle bracelet or something, right? In some ways. I think you go, what’s the next step and the next step after that? Once you start down the path, how far does it go and are there things that are going on that you don’t know about because we’re all really – not all of us I guess but a lot of us are pretty suspicious about what’s really going on in the background. 

With our phones, we all laugh from time to time about how you talked about kitty litter and suddenly there’s an ad for kitty litter on your Facebook page. Maybe that’s coincidental or maybe there’s something weird going on but we’re all a little paranoid right now.

[0:18:29.5] BR: Yeah, these are definitely interesting times. That’s contact tracing. It will be interesting to see how we integrate into that data and I’m glad you sent those articles over because it is something I’ve been trying to figure out. You know, one of the articles I threw out I threw out a bunch of articles, I want to save that one for the end but you know, Health systems must restart now to map out safe back-to-work strategies, this healthcare IT news article that was put out there and it just – it talks about you know, just some of the challenges that we have in front of us and I’m not going to go into the article too much because as I was reading the article, I was doing research on what health systems are doing. The most prominent being Atrium. 

Atrium is created their safe Atrium places to go and encouraging people to come back to the hospital and they’re expanding their surgeries and they’ve probably done the best job of integrating marketing and operations for creating that. Then I ran across University Hospital’s healthy restart playbook and if you haven’t seen this, this is worth looking at, it’s University Hospital out of Cleveland so and they have healthy restart for the community. It’s phenomenal. So they have, it’s essentially a playbook for any business that wants to go back to work and what you should do for your employees and it has a whole bunch of videos.

Keeping your employees safe, environmental safety in the workplace, building trust with your workforce, frequently asked questions, they have a UH healthy restart playbook. You know, this is the kind of stuff that it’s just really good just loaded with videos, loaded with bullet points on communicating with your customers and how to do that effectively. Just so much in this that I was like, you know, this is one of those things that we should be borrowing or whatever but isn’t this the kind of stuff that people are saying, the information we want right now. 

A health system is uniquely positioned to be that trusted source of information to say okay, we’re going to partner with the businesses in our local community to help them go back to work effectively. Are you seeing more of this or are this pretty early on and isolated with UH and Atrium at this point?

[0:21:18.3] DD: I actually – I probably have about eight or 10 of those articles that I’ve fished out in the news over the last seven or eight days and every – it’s everyone from health systems to companies like Salesforce who are talking about here are the things you need to do to make sure that you’re building trust and employees and customers to bring them back to your store or back to the office or whatever the case may be and like you said, it’s a lot of the stuff like you need to figure out deep cleaning.

Many of you have never really done that before and now that needs to be a thing and you need to talk about it and how it works. You got to have hand washing stations, you need to have gel, you need to maybe rethink how if it’s an office, how you layout desks and how people travel up and down the aisles. There’s a lot of that stuff. I’m with you Bill. 

I think this is a real opportunity for health systems to show their leadership in their community as people who are public health and infection control experts and they really can provide great coaching free services to other people in the community about this is the way that you should behave, these are the things that you should do because we’re still in the middle of all of this and you know, this is your obligation. If you’re going to open up, these are the things you need to do to help us make sure that we continue to flatten the curve.

There’s a lot of stuff that is not – it’s not super expensive or really complicated, it just needs to be talking about by experts that you know and trust and in most health communities, the healthcare organizations are the organizations that are probably, when you look at the trust index in most communities, they are the organizations that communities trust more than anybody else. 

[0:23:07.6] BR: Yeah, I’m looking at the section. 

[0:23:09.3] DD: Take advantage of that.

[0:23:10.4] BR: Yeah, I’m looking at keeping your employees safe and they have some of the things that you were just rattling off they have but then they have a video, you know? Physicians standing next to the logo of the university hospitals, Cleveland Medical Center, you know, lab coat, purple tie, glasses, looking smart and he’s talking about what is an antibody test and who needs it, and then you go a little further. I’m sure a physician in the lab coat as well, COVID 19, Why we should wear masks. One on physical distancing and how we social distance in the workplace.

[0:23:48.5] DD: Those are short and sweet and easy to understand videos that are kinds of things that you can actually have your employees watch before they come back to work as part of their reentry program, right? I mean, you know, to make them and the organization more comfortable. I love that UH is doing that. I think that you know, I’m with you 100%. It’s a great thing for healthcare organizations to you know, take the task of helping the rest of the community, come back and be healthy and stay healthy and know what to do, know how to behave.

Because it’s different from how we were behaving three months ago.

[0:24:31.6] BR: Yeah. Hey, I’m going to close with this question. The podcast with this question. Which David Chow asked out on LinkedIn and I thought it was a good question, it’s an interesting question. I’ve been asking people recently of I’m curious what your thought is. When will revenue, hospital revenue return to pre-COVID levels?

[0:24:55.8] DD: Man, I mean, great question. 

[0:24:59.3] BR: This is where you earn your money Drex.

[0:25:01.6] DD: Great question. I think even if we clicked on right away and said, all the elective surgeries we’re doing, we’re going to start doing those again, I don’t think we can cram all those through the system. In the new system that we probably created or the new system that we need to create. It’s all of the new screening processes and getting people to – and process the way they do, you know, people that we would test now that we didn’t have a testing step in there before. 

All the PPE changes and swaps that we have now which we talk about the consumption of all the PPE but there’s a big time factor on all of this too. I don’t know if you’ve ever actually watched nurses or doctors pull this stuff off and then put it on again but it doesn’t happen in like a minute. It takes them a little bit of time because it really is like a de-con process that they’re going through to make sure they’re not contaminating anything else. 

So I think capacity has also shrunk, which means that we are going to have to probably think about how we do a lot of stuff that we do today to become more efficient so that we can eventually get back there. Yeah man, when though? I don’t know. Maybe we’re a year away from being back to pre-COVID revenue numbers or even starting to get close in figuring out how we need to call her right up to the line to be able to get back there. It’s going to be a while. 

[0:26:34.0] BR: Yeah and you know, I saw on his post I answered Q3 2020 – or I am sorry, Q3 2021 and so that is not too far from what you’re saying. 

[0:26:46.1] DD: A little over a year, yeah. 

[0:26:47.3] BR: But to be honest with you there is part of me that says never and the reason I say never is you know, we’ve known for quite some time that there is an awful lot of stuff we do as very precautionary. You know putting people in the hospital, running a battery of tests and some surgeries and I don’t know, we just know that we err on the highly cautious side and it generates an awful lot of revenue that you go for a couple of months without it.  

You change the model of care with the advent of telehealth and remote patient monitoring and other things. We may not see those revenue numbers again, that is the bad news. The good news is we have introduced some really efficient and lower cost ways of providing potentially the same level in quality of care for our communities. 

[0:27:46.6] DD: I think too that if we think about the work we’ve done with telehealth and you know alternatives to coming to the hospital and going into the hospital, that really plays nicely into the transition away from in person visits to the models of –

[0:28:15.0] BR: Yeah, the [inaudible 0:28:15]. 

[0:28:16.4] DD: Right, exactly. Pay us a fee and we’ll make sure that you stay healthy. I mean it is almost like there’s – did we get some wires crossed in the middle of all of this? I think there is a real opportunity to take advantage here now of some of the things that we have learned in the new model of health care. We just have to take advantage of it now.

[0:28:36.5] BR: Yeah absolutely. All right, well that’s all for the news section to the show. Special thanks to our sponsors, VMware, StarBridge Advisers, Galen Healthcare, Health Lyrics, Pro-Talent Advisers for choosing to invest in developing the next generation of health leaders. The show is a production of This Week in Health IT. For more great content, you can check out the website at or the YouTube channel as well. 

If you want to support the show, the best way to do that is to share with a peer. The second best way is to subscribe to the YouTube channel and if you want to catch the tail end of this show, please jump over to the YouTube channel right now to watch Drex and I talk about a business centric IT approach to reopening. Thanks for listening, that’s all for now. 

[0:29:19.5] BR: Well that was all for now, now we are in the YouTube portion of the show. I don’t know how to do that transition. Maybe I should do another sound thing or whatever but we won’t do that. Drex, thanks again for taking a few more minutes to hang out with us. 

[0:29:33.5] DD: Of course.

[0:29:36.2] BR: You know, I mean we are going to get into this but what is the one thing that is top of mind for you right now? 

[0:29:40.3] DD: Just in general? 

[0:29:45.2] BR: Yeah, I mean with this COVID thing and healthcare, what’s top of mind? 

[0:29:49.6] DD: You know we just came off this topic about how long before we get back to normal from a revenue perspective and I continue to have a lot of friends that work in small and mid-size health systems who are really struggling right now like really struggling right now. They have burned through tons of days cash on hand or at the point where they are really kind of hoping that that government deposit happens tomorrow. 

I think it is going to change a lot of our rural healthcare situation and I am not totally convinced that this is for the better. So I worry about that. A lot of America is rural, a lot of them don’t have many ICU rooms. The process that we have taken in all of these to shut down elective surgeries has really hurt a lot of them and it is not just that it’s hurt a lot of them, a lot of them have been barely hanging on anyways. So anything was going to make them have a hard time financially. 

A harder time financially they were already having. So I worry about what is going to happen in small and mid-size health systems and are they going to continue to exists or are they going to be absorbed by bigger health systems or what’s the story. 

[0:31:12.4] BR: Yeah and that’s I think the same for me. I mean what does business as usual look like? How much revenue has been lost, primarily these are the things that are – you know what is our new pair mix in our community? I don’t think we are going to assume the pair mix of pre-COVID is the same pair mix coming out of this. You know it is interesting and then the conversations I am having the – just the people, we had mother’s day. 

So we have the Zoom calls to talk to everybody in the family and whatnot, just the conversations, we are getting to a point in our society where there is a lot of finger pointing. So here I am in southwestern Florida and they opened the beaches and somebody saw that they were crowding and they closed all the beaches again and you are creating these sort of tattletale on the playground kind of thing and it is not healthy. I don’t know. I am not recommending anything here. 

And we are not talking about health IT but the culture right now is getting a little bit toxic for my liking I think. Even on the family calls you have different perspectives coming back and forth. You get to see people getting upset and it’s hard.

[0:32:36.9] DD: I mean it is a very judgmental situation. I mean people want to see their family members who live just right across town but they haven’t seen them now for two months. The sun is out they want to go for a walk, they want to drop by but to do that sometimes there are other people – when you tell them I am going to walk over and see my mom tomorrow, they get very judgmental about it. “Oh I am not sure I would do that. I don’t know, that doesn’t sound like a good idea,” right? 

And then you start to second guess yourself, which maybe that is all good but it is a little – you’re right, there is a lot of judging of what everyone is doing right now and some people are super judgey and some people don’t have good judgment at all. That’s also the problem right? 

[0:33:31.1] BR: Yeah, all right as I said, Drex and I put together a presentation based on what we’ve heard on the show and we mapped out what we think is coming next in healthcare and health IT and in this section of the presentation we talked about navigating the financial challenge that is upon us and as you were eluding to and earlier in the presentation we made the case that we’re moving from one crisis to another. We are moving from a pandemic to a financial crisis in healthcare. 

And the question we were trying to answer is how can a health system navigate out of the pandemic while mitigating the financial crisis and you know, we’re going to give – there is seven bullet points here. We are going to talk about them. At the end of the day to be honest with you, we had other slides in there. We talked about some mitigating factors and if you had a bad balance sheet coming into this, you’re struggling so hard right now just to keep your head above water. 

That you are going to hear some of these things and go, “How can we even do those things?” I mean we understand that every health system is really at a different point based on a balance sheet. We made that point earlier and the other thing I would say is we’re really approaching this part of the deck from a health system perspective and not necessarily a health IT perspective. You know I will just start throwing it out there. So for the first main action we have is restart your economy. 

And I am not talking about – I am talking about really restarting your health system’s economy and that means you know, people have to feel safe. They have to feel safe in your community. They have to feel safe going back to work. They have to feel safe coming back to the hospital and you know, we need to make sure that we’re squarely inserting ourselves in that conversation, not just the people who point out when we aren’t acting appropriately and at the later part of the podcast, we talked about the university health system. 

And you talked about a bunch of articles that you are going to highlight in 3xDrex and that is part of what we have to lead into and lean into is how are we helping the 7/11 to open up, how are we helping restaurants to open up, gas stations, grocery stores, whatever and I know some of those are already opened but how are we helping them to open up because until we do, there is going to be a continued strain on our financials for the health system if you can’t – Until the economy opens up, the health system economy doesn’t open up. 

[0:36:03.8] DD: Yeah and you know trust as you said, trust is a vital component to that and the idea of having this playbook generated by a health system, it gives people a benchmark against which to judge whether or not they or others are doing the right thing. Somebody’s got to set those benchmarks, otherwise, people will invent whatever benchmark they want to invent. Maybe that is part of the challenge that we have right now is that there is no authority that anyone is willing to listen to. 

Because anyone who should be an authority seems to have abdicated a lot of that authority now. So when you look at health systems and as we talked about in the show, some of the most trusted organizations in any community is going to be your hospital or your health system. For them to be able to step into that gap and say these are good things and these are bad things. You should do this and you probably shouldn’t do this, gives everybody something to measure their own behavior again, which may be as much, if not more than what everybody needs right now. 

[0:37:15.2] BR: Yeah and that is the second point is restoring trust in the health system and you know the reality is, we shouldn’t have anyone, governor, president, city council, these should not be the trusted authorities for healthcare in the country. It really should be Cleveland Clinic, Mayo Clinic. It should be the health systems in the local community who are helping to set the guidelines and helping people to understand the guidelines and helping people to understand the data moving forward. 

And one of the challenges is we did a great job. We told people to stay away from the hospital and you know what they are doing? They’re staying away from the hospitals. We’ve got to turn that thing around and help them to understand when it is safe and expected to come into the hospital and one of the points that you’ve made before I mean this is really a time for marketing to shine, you know? Let’s get the message out. How do we get the message back out that hey, we have some safe ways to engage with us? 

[0:38:16.0] DD: Yeah, I mean I think you think about being transparent and being as clear and easy to read as possible and that is the chance to talk about all of the things that you are doing to make sure that your hospital and your lobby is as safe as possible, that your exam rooms are as clean and as safe as possible and that is just describing all of the things that happen to make sure that they’re clean and that they are disinfected and that here is all the steps that we are taking to make sure that we check you at the front door, that if we are valeting your cars, here is what we do to make sure that we keep your car clean, all that kind of stuff. All of that information that you think people might just take for granted that of course we’re doing that, they don’t take it for granted anymore. They want to know, they want to know what you are doing and if you can tell them that, if you could be really clear with them that boosts trust greatly. 

[0:39:14.1] BR: Yep, that is what we saw in the Atrium example. So now we get to the point of okay, they’re trusting the hospital again. The economy is starting to go again and now we are at this point of, “Okay, we have two months of revenue, how much of that is lost and how much of that can we recapture?” and so the third point is, you have to figure out a way to recapture lost revenue and we talked about the safe environment. 

But now it’s how do you identify all of that stuff that was going on that really needs to be scheduled? Do you increase the number of hours in your OR, in your emergency centers and clinics? When are we ready to push the throttle down and say let’s get as many people in as possible? 

[0:39:58.9] DD: Yeah, I think that there is certainly capacity issue right? I am also married to a Canadian and so many of my family members are Canadian now and they were talking about how in the Canadian system there is already a backlog on elective surgeries and now there is a really, really long backlog on elective surgeries and the only way to resolve that is to increase capacity and make sure that you’ve got throughput that you need to be able to drive that backlog down. 

But that requires more hours and more time and maybe more OR’s or at least more OR hours and you do that by maybe doing weekends and other things but you also have to be really careful again from the perspective of it only takes one, “Oh crap” to erase a thousand, “That a boys.” You have one infection happen in an OR that becomes a big public story, all your trust is gone in a blink of an eye. So you have to be very thoughtful and very careful about all of that. 

I think there are ways to increase capacity and I think that a lot of healthcare organizations will do that. As important as anything else, is probably making sure that people who had elective surgery scheduled that their elective surgery procedure doesn’t turn into an emergency issue, right? So there are a lot of things that were just inconvenient and painful, a hip or something but at some point, you know it becomes like, you know this is no longer elective. This is a thing that has to happen. 

So you are going to have to do some triaging I think with those patients too to make sure that the ones that really need to be treated will get moved to the front of the line and that may mean that other folks are going to have to wait or as you increase capacity, you are going to able to get them through but I think that is a tricky conversation. It is going to be a lot of work for a lot of health systems to figure out who moves to the front of the line quickly. 

And for what reason, what is the protocol? But if you have the rules and you talk about what the rules are again back to transparency, it’s hard to argue with it. 

[0:42:16.1] BR: All right, I will take the one no one wants to talk about which is reduce your cost structure. We try to answer the question of when will we return to pre-COVID levels and both of us are saying sometime next year and you – I was talking to someone and it was actually one of my clients and I said, you know you should be modeling. Actually probably should have been modeling from the day you stopped taking elective surgeries what the impact was on your revenue. 

And I am sure they did but they should also be modeling different run rates for hey, let’s assume the return is in Q4, let us assume not until Q1, Q2, Q3, modeling doesn’t cost you anything. I mean it is just somebody’s time putting it on a spreadsheet looking at the model so that people can make a determination based on the facts and based on what their beliefs are. So those models you know we had a phenomenal CFO at the health system where I was at. 

And she would have had like five iterations of different models on even before this would have been a significant issue and we would have been talking through those models from day one because you know if our run rate coming out, if our run rate going in was six and a half billion and our run rate all of a sudden drops to like a run rate of four billion, we don’t need 19,000 employees. 

[0:43:41.4] DD: Yeah, what are we going to do? 

[0:43:42.8] BR: Yeah, we’ve got to start fielding those questions. I am not – there is no magic bullet here. Everyone knows there is no magic bullet. We have furloughed a lot of employees, 227 systems I think that last count have furloughed employees. This is going to impact budgets one way or another. So you might as well start to have the conversations now, which projects are related to either reimbursements or related to cost savings. 

I think this is where soft dollar savings go out the window and it is only hard dollar savings and it as immediate as possible in hard dollar savings and you know there is just no getting around it. You have to reduce cost structure in some way, shape or form. 

[0:44:31.4] DD: It is you know, one of my CFOs and I mean one of the best people I’ve ever worked with, I mean they were money ball spectacular analysts, right? They were always thinking about here is plan B and plan C and plan D and plan E and plan F. If these things happen, here is what we would do. So there wasn’t a lot of time sort of generating things from scratch when something went bad. It was always like, “Ah that’s a plan B situation,” and they would pull up plan C or plan F and that’s what we would do. 

Everybody I mean, it was a great place to start, right? I think about my days in the military. We were always either in a crisis or we were planning for a crisis and so you had lots of plans for lots of different crises and when something happened, you had some plan that was kind of like the crisis that you were facing and you at least knew where to start and I think for most health systems and when you look at IT shops, you got to think about it the same way. 

If we were asked to reduce by this much, what would we reduce? Part of that conversation has to be a regular conversation with your clinical and business partners. Understanding that in a healthcare IT department, almost none of the stuff that you run, you run because you want to run it because it is good for you. You are running it for business or clinical partners. So if you are going to cut, you need to have conversations with business and clinical partners about: 

“If we cut these people that means we are no longer going to offer these services,” or we are going to turn these applications off and they need to be ready for that. You are a part of that team, they’re a part of your team. You can’t just say we are going to keep doing what we are doing with half the people. That is not a recipe for success and that really goes across the board. 

[0:46:26.1] BR: All right, we’ve got four minutes to go but another thing I will say on that is and I want to go back and I won’t say people negotiated poor contracts although we did but with this now in your head, think through this the next time you negotiate a contract. Think through, you know they easily scale up. Think of writing your contract so that they scale back down. They have to scale back down because nobody anticipated this. 

And if your cost didn’t change and your revenue dropped by $500 million then that is not a good contract. So wow, four minutes, five minutes. Capture government dollars is our next point and we talked about the telehealth, there is telehealth grants out there. There is remote patient monitoring grants out there. Are there any other sort of come out since the last time we talked about this? 

[0:47:21.7] DD: I don’t think so. I mean the only thing what I always worry about grants is that you get grant money and then you do a thing and then at the end of that, take grant money as a way to kick start something that you are actually going to be able to turn into a business line and is going to make money because when you take grant money just to do a pilot and there is no exit from the free grant money that just disappoints everybody involved so think about that. 

[0:47:53.2] BR: Yeah, the telehealth, I had to read this. So I read the telehealth thing that was in the CURES Act or not the CURES Act, whatever that cares, that CARES funding. It is so broad I mean – 

[0:48:09.4] DD: Almost anything.

[0:48:10.9] BR: Almost anything to drive through that hole. 

[0:48:13.1] DD: Telephone calls. 

[0:48:14.2] BR: Exactly, the sixth point we had on this was take advantage of disruption. You know, one system’s pain is another system’s opportunity really. So some systems aren’t going to make it, what is your plan? You know, you can look around at the market right now and determine who is going to struggle coming out of this. You can look at it as an opportunity for strategic partnership and if you know you’re going to be the ones that struggle, you might want to reach out earlier. 

It is better to do those deals earlier on than it is when it is like, “Hey, if we don’t get a deal we have to…” and you know this, “We are going to have to close our doors,” but disruption, when you hear the word disruption, think opportunity. Disruption equals opportunity for someone. If things are changing rapidly that is what happens and then the last one, adapt to capture reimbursement dollars. So this is where we talk about and I’ll let you close out here. 

You know we talked about the opportunity here. If CMS continues to fund telehealth and remote patient monitoring and the commercial payers follow suit, what is the opportunity here? 

[0:49:23.7] DD: Yeah, you know I think there is a ton of great opportunity too. I mean back to the other one, to disruption. Now there is a great opportunity here to do some things unlike any of the things you have done before and don’t be afraid of that. I think the other part of that too is as you are in the middle of this and you made some decisions that you thought were really good decisions and you find out that those are the decisions now in this situation that are eating your lunch, don’t be super prideful about, “No that is my decision so I am going to keep doing it.” 

Sometimes you just got to cut bait, right? You just got to let it go. That was a great decision at the time but given the current circumstances, that isn’t a thing that we should be pursuing. Don’t be afraid to let that go, adapt. 

[0:50:12.6] BR: There you go, that is the last word. So restart your economy, restore trust, recapture lost revenue, reduce the cost structure, capture government dollars, take advantage of disruption, adapt to capture new reimbursement dollars. So that’s all we have for this show, the extended show. Drop me a note, tell me if you like it, don’t like it, maybe we’ll do it again at [email protected]. Drex, thanks again for coming on the show. I appreciate it.

[0:50:39.6] DD: Always happy to be here. See you all later. 

[0:50:42.6] BR: Take care. 

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