This Week in Health IT
October 13, 2020

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October 13, 2020: Ransomware attacks. What should a CIO’s strategy be? How do you manage third parties? Do you have a critical vendor risk management program in place? Drex and Bill break down the Blackbaud example. Patient first, patient first. It’s always about the patient. What would a health system look like if they actually committed to customer service? Can we mirror Amazon’s principles? Is this even possible in healthcare? Big tech companies are blowing a collective raspberry at the House’s antitrust report which accuses them of using their platforms to squash competition. Hmmm. And settle back for some armchair quarterbacking as Bill and Drex discuss what qualities the new Haven CEO should have and why that person needs to upset the apple cart. 

Key Points:

  • Commercial payers are pulling back funding for telehealth [00:05:25] 
  • Anthem and United Healthcare no longer waiving copayments and deductibles for some customers beginning Oct 1 [00:05:35]
  • Physicians are the biggest drivers of telehealth adoption [00:09:05] 
  • Amwell Expands Partnership with Tyto Care [00:10:40] 
  • Do preventative security measures actually work? [00:21:40] 
  • Atul Gawande’s role as Chairman of the Board of Haven [00:33:40] 
  • U.S. House Judiciary Committee antitrust report [00:40:45] 
  • The Google and Apple monopoly vs the Epic and Cerner monopoly [00:41:00] 


News Day – Drex and I discuss Blackbaud, Antitrust, Haven and Telehealth funding cuts

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News Day – Drex and I discuss Blackbaud, Antitrust, Haven and Telehealth funding cuts

Episode 315: Transcript – October 13, 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.

[00:00:00] Bill Russell: [00:00:00] All right before we get started. I want to apologize because what you’re going to hear on this show is what happens when you don’t have a good DR plan in place. I have work being done on my house and they have been flipping on and off electrical switches throughout the day. And just prior to the episode, they had flipped off the power to my mic. So even though I had it right here in front of me, it was picking up the audio from the computer because the mic was not powered on. [00:00:30]  it will sound a little echoey. 

[00:00:33] Again, great conversation  Drex is awesome as always. And we discuss a lot of interesting topics today. I want to take this moment to just remind you about clip notes. Clip notes is growing rapidly. And the reason for that is it’s a great resource. It’s a great resource because, we’re busy, right?

[00:00:52] We have lots of projects going on. We’re not going to conferences as much anymore.  our training budgets have gotten cut. we just don’t have [00:01:00] time for things.  And what we’ve done is we’ve taken these conversations. It’s with industry influencers and these conversations about the news, right?

[00:01:07] And we boiled them down to a single email that you’ll receive. It’ll have a single paragraph summary bullet points, and then you’ll have four clips and you can just click on those, get a feel for what went on in the episode. 

[00:01:18]if you haven’t signed up yet again all you have to do is send an email to clip notes. C L I P N O T E [email protected] And you’ll get an email back. That’ll start the process to get you signed up [00:01:30] now onto the show.

[00:01:37] 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 and we’re going to talk Haven, Blackbaud, antitrust. We’re going to talk commercial payers pulling back some funding for telehealth and what the impact of that’s going to be. A lot of fun conversations.

[00:01:55] My name is Bill Russell, former healthcare CIO, CIO, coach consultant, and creator [00:02:00] of This Week in Health IT. A set of podcast videos and collaboration events dedicated to developing the next generation of health leaders. I want to thank Sirius Healthcare for supporting  our mission to develop the next generation of health leaders.

[00:02:12] Their weekly support of the show this year has allowed us to expand and develop new services for you and the community. Special. Thanks again to Sirius Healthcare. If you haven’t signed up for 3xDrex yet it’s a service of Drex DeFord are our cohost today for the news. And what Drex does is he [00:02:30] vets news stories for you. And he will text you three times a week with three stories that he believes are relevant. And as you listen to him, that, his perspective is phenomenal and he picks out only the best stories and the stories that you need to know as a health IT professional to get signed up text directs to four eight, four eight four eight.

[00:02:51] Now let’s get to the show. Drex DeFord is in the house to discuss the news. Good mornin Drex. Welcome back. 

[00:02:58] Drex DeFord: [00:02:58] Hey, thanks. Glad [00:03:00] to be here. Always a good time to be had. 

[00:03:03] Bill Russell: [00:03:03] Dressed in black. Is there a reason you’re dressed in black?

[00:03:06] Drex DeFord: [00:03:06] Not really, but if there was a reason to be dressed in black, it would be a, the passing of Eddie Van Halen. One of the great rock and roll guitarists that, people of our age grew up with. Awesome. just, he had all of his flaws and all the issues that all of us do and especially rock and rollers [00:03:30] do, but man, you can’t say anything about the way that the guy played guitars. Sad to see him go.

[00:03:37] Bill Russell: [00:03:37] Absolutely. I, I don’t know where to go on that because to be honest with you, you’re one of the cool kids. Everyone knows that we’ve listened to this show. You’re one of the cool kids. Van Halen and ACDC. these are whatever I, of course, was listening to Broadway music and Barry Manilow and Digby. Hey This is really good music. So we may not be, [00:04:00] have run in the same crowd. 

[00:04:00] Drex DeFord: [00:04:00] Okay. Maybe not, maybe not. 

[00:04:04] Bill Russell: [00:04:04] Oh, man, I should rerecord that. Make sure that, just to take that out, I don’t even know. I would say that we’ve got a lot of news today. We’re going to revisit a conversation we had almost two years ago about that’s the, the Berkshire year, Amazon, JP Morgan, venture.

[00:04:24] And we’ll come around to that. That’s gonna be fun. We’re going to talk Blackbaud. Because a lot of health systems have [00:04:30] been impacted by this. We may talk a little antitrust since the report came out, the majority of staff report with recommendations on competition. And it has some implications in healthcare so that’s going to be good. But since last time you were on the show, we introduced this whole concept of LinkedIn conversations where every weekday morning I go out and I share a new story and I put a little commentary on it. And we get some feedback from the [00:05:00] community, which is great. And, just start the conversation there.

[00:05:04] Drex DeFord: [00:05:04] I do my best, not to comment on everyone and I try not to lead the witness. 

[00:05:10] Bill Russell: [00:05:10] Try not to lead the witness. I appreciate that. So let’s start, we’ll start with the LinkedIn conversations and, let’s see which one. Should we start with, let’s talk about the pull back and funding. I think that’s a big, Yesterday I posted, the lack of funding [00:05:30] from telehealth will that cause a pullback in the use of telehealth.

[00:05:34] And here’s the center of the story is that two of the largest health insurers, Anthem and United healthcare are no longer waving copayments and deductibles for some customers beginning on October 1st. And it says while the virtual visit is likely to be much cheaper than going to an emergency room, you could end up paying anywhere from 55 to $92. The average cost of a lengthy tele medicine visit within your plants and network. [00:06:00] And likely, the pullback of funds will cause a change in the use of telehealth. Yeah. What are your thoughts on this? It’s interesting to me that we’re still telling people, hey, be cautious, do social distancing, wear masks, do the quarantine after travel.

[00:06:21] We’re telling people to do that. And now these major payers are pulling back the funding and say, yeah, but in this case, go ahead and sit in the waiting [00:06:30] room and go see a doctor. 

[00:06:31] Drex DeFord: [00:06:31] Yeah,  I feel like it’s diametrically opposed to the thing that we’re actually asking people to do and what we want.

[00:06:39] So there’s an unintended consequence clearly. That will happen to at least some patients where they will either go and infect somebody or they will be infected by somebody else who’s in the same room with them and they could have done a telehealth. It may cause a telehealth visits to drop. We’ve seen a little, [00:07:00] drop-off surprisingly, some of the metrics that I’ve seen have shown like inpatient visits coming back, but telehealth visits holding steady, or maybe only dropping off a little bit, still multiples over. What they were at the beginning of the pandemics. So telehealth has definitely taken hold.

[00:07:17] I think the thing that worries me more, longterm is how are they going to deal with cross state licensure and, are they going to put those other things in place that helped keep, [00:07:30] telemedicine, running right. Or being allowed, not being obstructed by some, obscure or weird regulation about needing to place your hands on the patient before you can build for us, a service.

[00:07:49] Bill Russell: [00:07:49] There was really three things, right? So that the money was the biggest thing. Yes. CMS lead the way. And then you have the private payer. So the money being the biggest, the next thing was the regulatory [00:08:00] environment. Which is a practicing across state lines and they have a special dispensation in place right now where essentially the federal government is overriding the States. That’s not going to last, the States will eventually push back and say time out. we’re a Federation of stage. We are not a federal, federal run type of entity. So there will be some pushback at some point while to figure out what that looks and then the [00:08:30] third was just the adoption rates, right?

[00:08:34] So the technology has always been there. I think almost every health system might work with that. Some aspect of technology, some is better than others, but at the end of the day, there was a technology foundation in place. There was adoption. How do we get our physicians, our networks, and our clinically integrated networks to use the technology.

[00:08:53] And so that’s the piece. That has cultural and adoption users, [00:09:00] of patients. That’s the part, which I believe to be honest with you, I believe is primarily driven by doctors saying, Hey, I’m going to see you as soon as the doctor says to me, Hey, I’d rather see you at a telehealth visit. I’m going to do that. They are the biggest driver of the use.

[00:09:18] So that’s what we saw in COVID. They wanted to use it. We gave them the technology to use it. We trained them to use it. They found it to really work effectively and they started telling their patients to use it, but [00:09:30] to sustain and to sustain it. I think the funding that, we will have the funding for Medicare, I don’t think the Medicare funding will pull back, but if the commercial payers pull back, I don’t like the message that sends.

[00:09:43] And I, I think what we’re going to see from the commercial payers is essentially. A two tier of insurance kind of plan. There’s going to be one that’s designed for the digital future. That’s literally a digital health plan. Hey, wear this sensor, [00:10:00] put these things into your home. Step on a scale every day, a nurse will be tracking, this kind of stuff, and we want you to do televisit first.

[00:10:08] All that stuff that’s going to drive cost out of the system. I think there will be digital health plans. And there will continue to be traditional plans. I don’t know I’m just pontificating. 

[00:10:17] Drex DeFord: [00:10:17] I think it’s an interesting idea, right? Would you pay less for a digital health plan because of all of the, at least in theory, all of the administrative and wait time and other things that you’re [00:10:30] beating out of the system, it should cost less. So you should pay less, right? 

[00:10:33] Bill Russell: [00:10:33] Yeah, absolutely. I agree. Along that same vein here, so Amwell expands their partnership with Tyto care to extend healthcare at the home. And I highlight this. I hesitate to carry somebody else’s water when it comes to marketing but I found this one to be interesting because Tyto Care handheld examination device, they have a lot of different things that they do want it. They can track heart [00:11:00] lungs, abdomen, skin, throat, ears, heart rate, body temperature. They can, they can track a lot of different things. and when you partner that with telehealth. Interesting opportunity, don’t you think? 

[00:11:12] Drex DeFord: [00:11:12] Yeah, I do. I this kind of, again, gets back to this, is there a digital package or something that you could, put together, send, you sign up and this this thing to the patient’s home and a lot of the stuff that you would need to do in person visits [00:11:30] for now, you’re able to do remotely. And it’s not just looking at a screen, obviously it’s a lot of other stuff that now you could, you could diagnose and treat remotely. 

[00:11:43] Bill Russell: [00:11:43] So are we turning like the parents or potentially, just myself as I’m doing my own care into the nurse assistant in this case. Is that what we are doing? 

[00:11:53] Drex DeFord: [00:11:53] Yeah, maybe. I think in some ways, you and it has a couple of [00:12:00] different, possible side effects, right? Unintended consequences again. One of those is that. The more you use that kind of a device. And the more that you understand how it works and what’s going on with it, the more informed you are about whatever that problem might be.

[00:12:17] And so you’re more likely to be able to pay attention to it and actually take care of it. So maybe, there’s a, there are good other good upsides to this other than driving out costs and saving people time. 

[00:12:29] Bill Russell: [00:12:29] Are [00:12:30] there unintended consequences? Hey, now that I have this device, I might use it and not call the doctor. Is that reallya negative? 

[00:12:38] Drex DeFord: [00:12:38] I don’t know. I don’t, I don’t know enough about how the device works, but I’m assuming that it’s a gather data and transmit it sort of device, Not something that in your hand, it’s not a star Trek, tricorder kind of thing, that you could point it at your knee and then it diagnosis you in place. So I don’t [00:13:00] know, I’m not sure about that. I think it’s probably just, it gathers information or gathers enough of the right kind of information to be able to transmit it to your doctor, to then get. Some kind of feedback. 

[00:13:12] Bill Russell: [00:13:12] I still want to tricoder every time I watch it, I’ll pull up an old up. So do you use some of the new ones and they just wave it over? Everybody goes, it looks like he has a laceration, it’s like, are you kidding me? You tell just by waving this thing over people. 

[00:13:25] Drex DeFord: [00:13:25] And there’s lots of, stuff going on [00:13:30] outright, on, out there right now, in an experimentation phase that certainly have elements of that tri-quarter in it. I’m with you, I’m excited about the day that that comes. 

[00:13:43] Bill Russell: [00:13:43] All right. So w I had it pushed out here where I said, can health IT  security scale? And I talked about on last week’s episode, a little bit talking about the. VMware announcement, they’re, have some, free trials and [00:14:00] some of them out there, but what I want to talk to you, I want to come back to that question of can health iT security scale? You’re one of the security people I go to. but let’s start with Blackbaud. How serious is this? if you’re talking to a health system that’s been compromised at this point. How serious of a issue is this? 

[00:14:19] Drex DeFord: [00:14:19] Look, ,  we know that 38 organizations, healthcare organizations have potentially been breached in healthcare. 14 of them have already reported to health and human services, wall of shame saying, [00:14:30] We had something bad happen to us. There’s about 3.4 million patients, which means that in 2020, this is probably going to be one of the largest breaches. the timeline yeah. Is interesting. 

[00:14:43] The ransomware apparently got placed sometime in February. They discovered it in, in May. They sent out notifications in July that said, we, we had, some of our data has [00:15:00] been, may have been compromised. and then, at the beginning of the month, or right at the end of the last month, they actually sent an another notification and said, these social security numbers, these kinds of things actually are now on the dark web. And you need to notify patients and families. It’s interesting. If you go to the Blackbaud site and read their spin on this breach, their spin on this breach is that they stopped a breach. [00:15:30] In some ways I can, I can totally see that they stopped a breach from being a really bad horrendous breach and completely taking down all of Blackbaud.

[00:15:39] But realistically, there was some data that was exfiltrated and they’ve admitted to actually paying the ransom to make sure that the bad guys destroyed that data and received some kind of a certification from the bad guys that they destroyed that data. But these are cyber criminals, how much do you trust them?

[00:15:59] And at the same time, [00:16:00] there are other interesting things happening, right? They. If you, if you pay the ransom and, I think most cyber pros would say, don’t pay the ransom, but if you pay the ransom, obviously that’s going to create more cyber crime. You’re just funding, a bunch of thugs who are gonna, do bad stuff to healthcare IT, healthcare and healthcare IT. The other part of this is that you’re a known payer now. So [00:16:30] we’re going, we’ll be back, you’re, you’re, you’re going to be a return customer. 

[00:16:34] Bill Russell: [00:16:34] Yeah. 

[00:16:37] Drex DeFord: [00:16:37] Yeah. And the third thing that’s really interesting is, I think late last week, the treasury department issued some, notices or advisories that said if you pay ransomware, we’re probably going to come and have a conversation with you because we may very well need to find you because your supporting cyber criminal [00:17:00] activity.

[00:17:03] There’s a, there’s a lot of stuff going on. I think it’s a big deal. I think, as well with a lot of these breaches, the breach happens. They figure out what’s going on. They bring in forensic investigators, the FBI, others, they dig and dig and dig. And the more they dig, the more they find like, Oh, wait  a minute this isn’t what we thought there was more information than we thought. And then there are these updates that happened last week. And so we may even see more [00:17:30] of those out of this. 

[00:17:31] Bill Russell: [00:17:31] All right. Let me find tune that I had Blackbaud we used it for, donor management, essentially. There wasn’t a lot of patient information. There was more, our donor list and yeah, the 

[00:17:43] Drex DeFord: [00:17:43] Credit card numbers and maybe social security numbers. And in some cases there’s something to do 

[00:17:48] Bill Russell: [00:17:48] As a CIO how should I be viewing this at this point? 

[00:17:55] Drex DeFord: [00:17:55] This is an excellent opportunity for [00:18:00] you to talk to your board about how you manage third parties and how critical that a vendor risk management program is that you may or may not have in place.

[00:18:16] You probably have something in place to do vendor risk management. You have inventoried all of your third party vendors. Maybe you have a database that sort of describes all the data that is exchanged and how it’s exchanged and [00:18:30] what qualifies as PHI and doesn’t, you may be monitoring those network and traffic activities, through your SOC or through a partner, SOC, but there’s just, we’re in such a weird world today that, directors and managers who have a credit card have the opportunity now to go out and buy services without you knowing it. And maybe in the procurement of those services, they’re actually [00:19:00] sending PHI may or may not have signed a business associate agreement.

[00:19:04] And the bottom line for this too, for, I think for CEOs is that even when you sign a business associate agreement and it’s an airtight super good risk transfer, BAA it’s written into your contract and everything else, that clearly it doesn’t completely transfer risk because in Blackbaud’s situation, these health systems are still having to go to HHS.

[00:19:29] They got [00:19:30] to go out and notify donors in the middle of a pandemic where donations are incredibly critical to keep any health systems running. You’ve got to go out and tell them that, we partnered with an organization that may have compromised your data. If I’m a big donor. I’m probably going to have to rethink my whole donation strategy if I get that email, 

[00:19:54] Bill Russell: [00:19:54] Let me, so let me ask you this. So when I became a CIO, I walked in and security obviously [00:20:00] was in fact, I think it was six days into my being named interim CIO. We were breached. And I jokingly say, I wasn’t at fault because I wasn’t fall. I was six days in. Maybe I should have completed the audit before then and whatnot. But yeah, just get the contract done was more than six days. And then I started looking at security almost immediately. And then we had, we had well over we’re 30 [00:20:30] applications doing all sorts of different. monitoring social security portfolio was pretty large. We had way too many interfaces, if somebody went into this and some that there was an interface for this identity use different thing than this, whatever. And it generated way too many alerts. One of the first excuses I got was I, we, we can’t respond to it all these large, we can’t triage them fast enough.

[00:20:53] It’s generating too much information. And now this is back in 2012. And this is going to be my question, which is, and then everything [00:21:00] required  human intervention of some kind. How much have we progressed since 2012? Since that experience that I had. How far we progressed in health IT?

[00:21:10] Drex DeFord: [00:21:10] I think it depends on the organization that you’re in, but in a lot of places we’ve not progressed much. We, I think, and this is really broad generalizations. So if you’re offended by this as a CIO or a CIO, so please don’t be, in your heart that this is true. In many places. We love to, [00:21:30] buy technology that. We think is a silver bullet. And so it’s going to solve a problem in this area. And so I’m in security and a lot of organizations, we bought a lot of tools. We bought a lot of preventative measure kind of stuff, and we put it in place and those things are great. But very often they’re designed to send those alerts to somebody, right? Hey, look at this, look at this, look at this, that doesn’t look right.

[00:21:56] I’m not sure we should be talking to these guys. Shouldn’t this be blocked? I [00:22:00] don’t know if this is a thing, should these two things in the network be talking to each other and you got to do something about that. And, there are security operations center organizations who are, built I don’t, I don’t know if you want me to say one, but there are security organizations that are built that actually take that burden off your shoulder and take those feeds. And then because of the way that they have created the analysis stayed on the backend. They can actually sort [00:22:30] through it so that a thousand alerts become like three alerts and then they have expert sort of analysts to be able to go through that stuff and tell you when, we think this one is actually a problem.

[00:22:43] And so we need to research this with you. Those are, I think we, we’ve got to get better and better and better at this because it’s not, the tools are important, but yeah, it’s not about the tools. If you buy the tools and then you don’t do anything with them and in a lot of ways, what you’ve done, it just created [00:23:00] exposure for your organization right here.

[00:23:02] Oh, you knew all of that. Now that we go back, you can do the forensics after your, after your hack, all that information was available to you and you chose to do nothing about it. Great. That’s definitely not something I want. The HHS, inspection team to know about the organization. think carefully about how you build that security program and associated tech.

[00:23:28] Bill Russell: [00:23:28] So [00:23:30] I’ll start this comment by saying I did exactly what you just said. I did. I did outsource to a company that took our alert monitoring away from us. And, yeah, and they did a much better or drive and they were able to triage very quickly and they were able to raise alerts, almost on a daily basis. Our team. Just did there’s this collective sigh of relief. Not that, Hey, we’re not responsible for security anymore, but just, somebody is going to tell us, these are the ones you need to focus on [00:24:00] today. And we didn’t have to figure that out. 

[00:24:02] Drex DeFord: [00:24:02] I get to go back and do the job that I was actually hired for, which is what I want to do and part of the reason that I came here, I love the healthcare mission. I want to work on networks. I don’t want to spend half my day talking to chatty Cathy technology that tells me that, there was a squirrel over there and now there’s a squirrel over there

[00:24:22] Bill Russell: [00:24:22] But here’s the thing I don’t think that’s going to scale and this might be, Bill’s still searching for the technology [00:24:30] solution. I think this is the number one place that AI and ML can really, really face in security because an infiltration attack, typically they don’t look different from, it takes a while for them to develop something new. They’re using the same things over and over again. We know what they look like. We know what the patterns are. We should be able to see those on the virtual machine. We should be able to see those on the networks. We should be able to see those in a lot of different ways. And I’m looking for the complete fabric. That is going to be monitoring for [00:25:00] those events and identifying those events and potentially shutting down workloads so that they don’t get exposed or they don’t get locked in a in some sort of malware attack or lockout attack. 

[00:25:17] Drex DeFord: [00:25:17] Yeah, no, that’s the, that’s the key to the operation, right? You can take these feeds, you feed it into some sort of an ML machine that sees these patterns. And I think it is scalable because for [00:25:30] the companies who do security operations as a service, the more customers they have, the more stuff they see, the more they’re able to correlate attacks on hospitals, several hospitals at the same time, see what those are.

[00:25:42] And then they’re able to actually contact the client about what to do next. This is happening or in some cases, If the client would will allow it. They can actually go out and see, we are going to kill that printer. We’re going to kill that PC. Or we’re just going to turn off that part of the network [00:26:00] until we resolve this issue. That’s tricky. Yeah. Healthcare, right? Because sometimes if you kill a part of a network or you kill a device and you don’t know what it is, it could be an MRI machine or an X Ray machine or an IV pump, and you don’t want to do that. So it’s very sensitive. You have to be very careful about how you work your way through this, but, the tech and the services exist today. And I think it’s scalable because the more hospitals, the more healthcare organizations [00:26:30] that are on that service, the better opportunity they have to put out the kitchen fire before it engulfs the entire house. 

[00:26:41] Bill Russell: [00:26:41] Exactly. Yeah so last, last story I said, I would comment on otherwise I go into something else. Cause we were where we talked a lot about security there, but I think that’s what we did. It’s very relevant right now, the last one is what would a health system look like if they actually committed to customer service? [00:27:00] And Dale Sanders, who’s been on the show a couple of times and he shared a post based on an experience that he had. And  he pulled up this story and it caused me to think so what it had is have Amazon six principals around customer service and, I’ll just rattle off some for you. Relentlessly advocate for the customers. Trust our customers that rely on us use good judgment, [00:27:30] anticipate customer needs and treat their time and attention as sacred. Deliver personalized, peculiar experiences that customers love. Make it simple to detect and systematically systematically escalate problems and eliminate customers effort through this sequential and systematic approach, defect, elimination, self service, automation, and support from an expert associate.

[00:27:55] I just, I wanted to know, these are Amazon’s customer service principles. I just wanted to know, [00:28:00] is this even possible in healthcare? And, what are some examples of where this has happened that we used, Ritz, gosh, we were in Southern California, we used Ritz Carlton and Disney programs, different hospitals. So we didn’t, we didn’t really mandate as a system what to do, and some of our hospitals to Disney, and some were Ritz Carlton. And I’ll be honest, those programs, were pretty impressive and had a profound impact on the culture and delivery of care [00:28:30] in those, in those environments. So I have seen some of this being done and being done well, but, I’m wondering, is it even possible to take like these six principles and say, this is what we’re going to be about?

[00:28:47] Or does that create like a revolt where people go, okay, I’m going to advocate for the customers. Hey, you shouldn’t do this procedure. You should do this. You shouldn’t be in this hospital over there, and I’m not gonna use this cost because it’s going to [00:29:00] cost you 20 bucks on these, this one. Cause when we cost you five bucks, do we, it would be interesting to see if we, put these six things and said, all right, hospital act this way for one week. What kind of individual activities would happen as a result of. 

[00:29:16] Drex DeFord: [00:29:16] Yeah. I’ve written about this and we’ve talked about it before. Habits are very, very difficult to change the way people work. Very very difficult to change an organization. Culture is just incredibly difficult to change. [00:29:30] So bringing in Disney or bringing in Ritz Carlton, I’ve been in organizations where that’s happened before, seems like a really great idea. Six weeks out, a lot of it has faded away. Six months out.  the two people who are still trying to do something like that are considered, maybe they’ve addicted, they’re addicted. They become addicted to the gimmick of the Disney thing. And a year later, it’s all over with, so the. Important [00:30:00] part of this, I think is that if you want to make these kinds of changes in your health care organization, it can’t just be a onetime hit. You have to go back again and again and again, and you’ve got to look at everything through the lens of whatever your customer service tenants are going to be.

[00:30:15] And it starts with things like you hear people say patient first patient first, it’s always about the patient. The patient is in the center of the target. I called up my provider. three days ago. And, I went into the call [00:30:30] tree and the first thing in the call tree was if you’re a provider, press one, if you’re a patient, here’s your six options, It was still very provider oriented and healthcare has been built that way and is built that way. And I don’t, again, I paint with a very broad brush. I know there are a lot of places that have made progress, but, this is not. Something you do overnight. It’s not something that you send out an email and say, start acting this way.

[00:30:58] It is one of those things that [00:31:00] takes grit and, you’ve got to just stick with it and there’s going to be a lot of those hard places that you’re going to make your way through that. like how do you advocate for the customer? What does that really mean? that. Takes a lot more than the, the four words in that sentence. It’s requires a lot of exploration and testing and okay. 

[00:31:25] Bill Russell: [00:31:25] Let’s talk about one of the organizations talking about pushing through [00:31:30] and getting to the other side. So Haven, Amazon Berkshire. Huge promise. Two years ago, right? They were going to break down our health outcomes. improve primary care access by insurance benefits, make drugs more affordable, at least for their organizations first and then potentially for the market, leverage data and technology to drive better and better system overall.

[00:31:58] That’s what was the promise [00:32:00] of paid? And when it came out, they went out and hired us one day and we were all like, yeah, this is a positive, listen, this is somebody who really understands how their work’s going to go. the first peak of what they were going to do, they announced the formation of two pilot health plans, for 30,000 employees in Arizona, in Ohio, the plans were established in consultation with, Cigna and Aetna.

[00:32:25] Those plans launched from 2020 and included a free preventative [00:32:30] care, no co-insurance or deductible copays for in network, doctor visits as low as $15 and other incentive programs. and it’s, and they go on to say still unclear. And by the way, I’m reading from an advisory board came out. So, they announced Gawande, he has since stepped down, stepped down as the CEO but still is a board on the board. Chair of [00:33:00] the board in fact. So what that tells me is that the daily operations of the thing were too much for his schedule or that his interests were more around what was going on with COVID. And he’s Hey, I, free me up. This, this operations day to day thing is a little too much.

[00:33:17] So Chair of the Board is more strategic. He’s able to still guide the direction of it. and I’ve just hit, hit a couple more of these points here a while why [00:33:30] they shouldn’t be held at hold the entire burden of getting even off the ground. His step down from the CEO was a major blow to the firm while as a skilled surgeon and thought leader Gawande likely struggled with trying to handle day to day operations, Haven is unlikely to make much short term progress without strong CEO leading the way Haven’s challenges go far beyond turnover though, and likely stem from several issues, including and here’s the five issues they get, announcing the venture too early, [00:34:00] seemingly without any immediate strategy or products of its own. So it was a little premature attempting to disrupt the status quo for employer health costs by relying heavily on entrenched players and services, trying to fix too many big industry problems at once. Navigating the bureaucracies of three major companies that operate across different industries and establishing a nonprofit culture from those same three companies that happened to be heavily focused on making profit for [00:34:30] shareholders. All right. So I think I captured this, what, what they’re saying about this? Uh let’s let’s go to the challenges. 

[00:34:40] Drex DeFord: [00:34:40] Yeah. 

[00:34:42] Bill Russell: [00:34:42] Should we get to the challenges? Are there expectations well, where do you expect this to go? Will they be able to overcome these challenges? I think that’s the question. 

[00:34:54] Drex DeFord: [00:34:54] I think you gave me grief for this. I think at some point I said that when they finally changed the name from the 10 [00:35:00] word name that they had to Haven, it turns out that may be the biggest thing they accomplished with Haven so far and I still believe that. And, and, I think when it, when it comes to a tool, Gawande, this is, this is a guy who’s a great strategist. He’s a big thinker. He understands healthcare problems in a big way, but when it comes to, you and I have been there. If you’re an operator, if you’re, if you’re, in the trenches, in healthcare, it’s hard and it’s super complicated. And to quote the [00:35:30] president, who knew it could be this difficult? Healthcare is really, really. Challenging. And there are a lot of moving parts. And so when you get into this and you’re basically a employer organization, and you say we’re going to go in and change healthcare. A lot of people were really excited about it, but what we saw, I think ultimately is, these guys got into it and everything they grabbed onto was really slippery and difficulty to understand and to get [00:36:00] ahold of and, maybe they didn’t come from a healthcare background. And so they’ve really struggled. I hope they don’t go away. Ultimately I think they have good resources and good thinking, and they have a lot of good, engineering capability and they’ve got a place. They just have to find it. There’s a niche for them to make healthcare better but it’s not solving world hunger. It’s a niche. And they haven’t found their [00:36:30] place yet. that’s my sort of thinking about where they will wind up is they’ll find something. They can actually get a grip on and they’ll make it better.

[00:36:38] And if they don’t, you still have Amazon out there with pill pack and doing all the things that they’re doing to try to make healthcare better, but they’ve taken a very different approach to it individually as a company, They’re finding little tiny things where they can make it 2% better or, 6% better. And [00:37:00] maybe over time they develop enough experience that they can put it all together and make a bigger impact. But 

[00:37:06] Bill Russell: [00:37:06] Yeah, it’s, it’s interesting at the time. I think we both liked the hire of a tool Gawande into the role. I’ve really soured on that, to be honest with you. I, I think we’re going to see more happen in this space from Amazon, by themselves. In fact, you have seen Amazon do a bunch of stuff in their [00:37:30] local market. in terms of, the clinics and the care and 

[00:37:35] Drex DeFord: [00:37:35] Sure here in Seattle. 

[00:37:37] Bill Russell: [00:37:37] Yeah. They’re doing a ton of stuff. It’s interesting. I think they’ve accomplished more in the last two years that he even can even remotely. And I think part of that is, no fault of Gawande is his lens his perspective is from healthcare. So he approaches it like a healthcare person that says, Hey, these things are immovable objects. We [00:38:00] have to function it this way. Whereas, whoever does it, this needs to have a strong understanding of healthcare, but they need to be more entrepreneurial in bent to say, all right, we’re going to do something different. We’re not going to partner with Cigna and Aetna and create a plan for 60,000 employees that’s more. based on wellness, than sick care. we’re we’re going to, we [00:38:30] are going to fundamentally upset the Apple cart here, figure out a way to keep our employees. And, by doing that, we’re going to drive down costs.

[00:38:40] I’d like to see an entrepreneurial bent with some healthcare background rather than a, then a, is it somebody from a physician perspective from established healthcare? And again, I was really, I thought that was a great hire when it, 

[00:38:56] Drex DeFord: [00:38:56] I think we both, I think we both agreed, at the time, [00:39:00] that’s good, this guy he’s got, he’s got big vision. He can see, as the field, he’s going to bring something to that conglomeration that they don’t have right now. And. Yeah. you’re, you’re right. Some of this too is just, when you work in healthcare after a while, I think you do get to the point where it’s, I can’t, we can’t do anything until everybody agrees.

[00:39:24] That’s the right thing to do. And that whole delay game process that [00:39:30] winds up being beaten into us over time as healthcare people, we have to collaborate. We have to make sure everybody’s read in on this before we do something. Yeah. It, it, it doesn’t work in the, I think the kind of venture they were trying to create.

[00:39:45] Bill Russell: [00:39:45] Yeah. Also, keep in mind. One of the things we liked about him was he was he’s a researcher guy. He, so he was going to, he was going to approach this from a data-driven perspective, which I think was a good thing. [00:40:00] at some point. Those people failed to get things started is what I have something. Yeah. It’s get something done. Anything done? sometimes it’s is better than sitting back. Ah, this is, this is absolutely. Somebody’s going to say, Hey, you’re armchair quarterbacking. And I will 

[00:40:19] Drex DeFord: [00:40:19] Totally, absolutely are. 

[00:40:21] Bill Russell: [00:40:21] That’s exactly what we’re doing. but hindsight, I would say, and even today I would say, go find somebody with an [00:40:30] entreprenerial bent and I think we’ll see some things, we are, we’ve gone over a little bit. I’m going to hit this last story only because I think it’s timely and it’s the antitrust stuff. And, so the report came out just a couple of excerpts from the report. They’ve looked at all the evidence of how these big tech companies use their platforms to squash competition for the most part.

[00:40:58] And there’s stories, it’s [00:41:00] like Google either was a, a gentleman yeah. Who had celebrity net worth. So he had the net worth of 10,000 or so, 25,000 celebrities. He had a staff of 12 people. We collected this information, their website, organically was one of the biggest websites, for that kind of information out there.

[00:41:21] Actually it’s the biggest website for that kind of information out there. Google sent them a thing saying, Hey, we would like to tap into your, information for Google answers. [00:41:30] And they said, no, no thanks. And so essentially what they say happened after that is their search rank went down. Google started to assimilate that information and start to use that information for Google answers. And as now, when you type in a question for Google, there’s, there’s an answer at the top. So if you ask for the net worth a Taylor Swift, likely you’re going to get that from Google. You’re never going to go to another website and to which completely, decimated this

[00:41:57] Drex DeFord: [00:41:57] Whole business model, 

[00:41:59] Bill Russell: [00:41:59] Another one, [00:42:00] Google as well, same thing around song lyrics and Google’s defense. There was essentially that. I hate, song lyrics, weren’t owned by the company that aggregated on their own body, the authors and the music companies, therefore, they just went there, gathered the lyrics and now they make those lyrics available. It’s, it’s interesting that same kind of stuff for Apple there’s stories about Apple. It’s a 450 page report. I appreciate, [00:42:30] Sherrie Douvalle actually gave a bunch of. A commentary on it and the links to the pages to find that the appropriate stories. Apple with their app store. There’s a bunch of stories in there. Of people sliding away their lives to be on the app store. And part of the agreement quite frankly says, Hey, we will come. We have the ability to compete with you and you have no ability to come back at us and [00:43:00] they, they under, but when you’re, when you’re doing it through the app store, they know who your customers are, how much they paid for your app. where they’re located, how much they’re using your app. they end up with a wealth of information to compete with you, on the, on those things. There’s some more, Google stories in here. And then there’s also some Amazon stories and how much information Amazon is really bleeding, not only from their, from their platform in terms of, [00:43:30] resale and whatnot, but also their, the echo platform in the.

[00:43:37] Drex DeFord: [00:43:37] Yeah the Intel that they can gather. Yeah. It’s amazing. 

[00:43:40] Bill Russell: [00:43:40] So my question to you is, do we have the equivalent in health care?

[00:43:53] If I want to an app I probably needed to work on Epic and Cerner, right? 

[00:43:59] Drex DeFord: [00:43:59] Yeah, [00:44:00] no, I think, there’s. Clearly, two or three players that really dominate the market, Epic, Cerner and probably Meditech. We know that, in the Apple orchard, we’ve heard people complain about what you have to sign as an agreement, to be able to get an app into the app orchard. Is there. Is there a really, an equivalent today? It’s hard to say, [00:44:30] but I definitely feel like, Epic is very dominant and they have put together a lot of structure that says, if you’re going to work with Epic, you’re going to have to do it our way.

[00:44:45] Bill Russell: [00:44:45] You know what’s interesting listening to you right Now? Because I’ve been the same way. It’s I’ve read the agreements. You’ve read that you read us. They’re onerous. Our livelihoods depend on Epic clients not going, Hey, I’m not going to work with [00:45:00] Drex or Bill, because they said this, but I’ll come I’ll just come out and say, I think I’ve talked to these guys. And they’re saying, look, read this agreement. I read the agreement. I go, I wouldn’t sign that agreement but if I don’t, I don’t get access to 50%. Really, you have to sign that in order to do that. That doesn’t make sense. You essentially have to say, yeah, Epic can compete with me. Epic takes no liability. Epic’s API is may change and make, or break your stuff and [00:45:30] sorry. 

[00:45:31] Drex DeFord: [00:45:31] Yeah, no, you’re you’re I just had a friend of mine send me the, Epic KPI agreement and just was, he. Basically did exactly what you said. He sent me the Epic API agreement. He was like, what? You signed this? I’m not, I don’t know what’s going on here. And there was a lot of stuff in there. and the kind of nutshell of it version for me was, No, we’re going to publish API APIs and you can use them. And if it turns out that something goes wrong, we are [00:46:00] completely off the hook.

[00:46:01] And once the data goes through the API out to you or somebody else, and something happens with that data, we’re completely off the hook. And if it turns out the API doesn’t work, we’re off the hook. And there was a lot of, and I’m sure I. Totally have that wrong, but there was a lot of stuff in that agreement, that also said, and you have to sign this by Friday, if you want, access to the discounts for the API.

[00:46:23] So either way, I was just like, I don’t know what to think about that. Like where, where does, how, how, what do I [00:46:30] do? I can’t like, we’re going to throw out Epic tomorrow and install Cerner you’re, you’re you’re gotta do what you gotta do. Like you said, we’ve talked to a lot of Epic clients, a lot of friends who run Epic, who ran up against the same thing. And, and it’s not just Epic. it’s, it’s, once you’ve made an investment in these core critical clinical systems, you can’t just change boats. You can’t just change horses in the middle of the river. You gotta keep going. [00:47:00] And sometimes that’s to your detriment now, whether that’s antitrust or I’m not a lawyer.

[00:47:05] So I don’t know, but it definitely makes me feel uncomfortable as a customer that I’m. 

[00:47:10] Bill Russell: [00:47:10] We had those same things in the ERPs it’s once I choose to go to work days, I’m exactly, I’m not swap that out. I will say some of the things about Salesforce. The reality is, I look at Epic and I go, if I were in charge over there, would I write this agreement this way? Yeah, absolutely. I would. If I could. If I could say, [00:47:30] look, I’m going to wipe my, if you’re going to take the data out, which by the way, was there. 

[00:47:34] Drex DeFord: [00:47:34] Yeah, yeah, no, you’re right. No, they argued against this. Now they’re just trying to protect themselves. I see both sides of the argument. 

[00:47:44] Bill Russell: [00:47:44] In fairness, Epic is saying, look, if you stay in our world, we will protect you and we will make sure that you are whatever. And they’ve done a fairly good job of that. 

[00:47:52] Drex DeFord: [00:47:52] I agree. 

[00:47:53] Bill Russell: [00:47:53] And now the federal government’s come in and said, Hey, open up the API APIs. And they’re like, Alright, [00:48:00] we’re going to open up the APIs, but you don’t have, if you want, if you’re going to take data out the minute you take that data out it’s … 

[00:48:07] Drex DeFord: [00:48:07] It’s on you. And if for some reason, something doesn’t work the way it’s supposed to that’s on you. And if right, on down the line, I’m with you Bill. I see both sides of it, right? They did make a very fierce argument. Whatever it was six or eight months ago, or however long ago, it was that they didn’t want to do this. And I think it’s the, [00:48:30] again, it comes back to the, if you’re in the Epic ecosystem, then data exchange works and you can talk to other Epic sites and you can exchange data. And if you’re using apps from the. Apple orchard, the data exchange works and it’s supposed to work. And then, when you say open it up to everybody else, this is where, this is where they get defensive about their business model. 

[00:48:55] Bill Russell: [00:48:55] Yeah. and Drex and I talk, I’m salting work and I’ve talked to three Epic [00:49:00] clients this week and it’s absolutely strategic to their application rationalization projects. It’s up to just about everything they’re doing. And they’re willing to put up with a little bit here and there, what they considered to be a little bit here and there, for the benefits that they’ve received. And, we’re, we’re probably making, there’s probably some people that are like, yeah, let’s storm the Gates of Verona, but, before we started the Gates of Verona, just understand they’ve done a fair amount of really [00:49:30] great things for healthcare. and you don’t have a lot of, a lot of their clients. Who are, let’s let’s wrap pitchforks and go storm the case. They’re not in any way, shape or form. 

[00:49:43] Drex DeFord: [00:49:43] Yeah. We just had to go live here in Seattle. Seattle children’s went live with that pick a Saturday. And the the march continues. The conversion continues. People aren’t going to Epic because they hate Epic. that just, [00:50:00] isn’t a, it just, isn’t a thing. 

[00:50:01] Bill Russell: [00:50:01] Yeah. And we talked about customer service, they have phenomenal customer service. One of the CEOs I talked to last week said, yeah, Judy, we’re going to go live. And Judy has been on the phone for three or four of the calls. And, it’s what other CEO self-made bijillionaire is right out on the go lines. It’s like point [00:50:30] point well taken. It’s just, it’s it’s an unheard of level of customer service. Yeah. 

[00:50:35] Alright, that’s all for this week. Don’t forget to sign up for clip notes. Don’t forget to sign up for 3XDrex, two great services to keep you and your staff current a special thanks to our sponsors. VMware, StarBridge Advisors, Galen Healthcare, Health Lyrics, Siriuus Healthcare, Pro Talent Advisors, HealthNXT and McAfee for choosing to invest in developing the next generation of thought leaders.

[00:50:56] if you find value in the show, check out our YouTube channel, [00:51:00] shared with a peer. We would really appreciate it. Don’t forget to check back every time, Tuesday, Wednesday, and for shows, except for tomorrow, my parents are in town. I’m not doing a show tomorrow, so don’t tune in tomorrow. I will be hanging out with them. I don’t know what we’re going to be doing, but it’ll be fun. Drex, thanks for coming on. The show was always a great conversation. 

[00:51:19] Drex DeFord: [00:51:19] Thank you. 

[00:51:21] Bill Russell: [00:51:21] Thanks for listening everybody. That’s all for now.

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