This Week in Health IT Newsday with Vik Nagjee
March 22, 2021

 – Episode #

380

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March 22, 2021: Why is healthcare still about a decade behind? How can we start taking advantage of the cloud to get more flexibility and agility? How can we create faster, better and stronger consumer first workflows? Vik Nagjee, Director of Healthcare & Life Sciences for Sirius joins Bill for the news. Grand Rounds and Doctor on Demand have merged. Banner Health posted a 19% drop in net income last year. Michigan Medicine is moving forward with a billion dollar hospital. Amazon Care launched in 50 States for their employees. Plus the amazing platform Health Share, the impact of IRIS, robotic process automation pilots and the challenges of 5G.

Key Points:

  • The veto culture in healthcare is very challenging [00:06:53] 
  • What is the impact of IRIS to a health system? [00:10:25] 
  • Banner has an amazing M and A strategy. They’re super fast. They’re super precise. Clinical precision. Surgical precision. [00:24:55] 
  • Amazon Care is essentially a concierge level service for employees for an employer program. [00:26:40] 
  • Silicon Valley still barely understand healthcare [00:29:55] 
  • Coopertition with big tech is what is going to win [00:31:05] 
  • Transcarent are applying the Livongo playbook to the employer-sponsored healthcare system [00:31:35] 
  • There’s a whole new art and science around the patient room of the future [00:37:35] 

Stories:

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Newsday – Nerds Talk Technology Impact from Healthcare News Headlines

Episode 380: Transcript – March 22, 2021

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

Bill Russell: [00:00:00] [00:00:00] Welcome to This Week in Health IT. It’s Newsday. My name is Bill Russell, former healthcare CIO for 16 hospital system and creator of This Week in Health IT, a channel dedicated to keeping health IT staff current and engaged.

[00:00:17]Special thanks to Sirius Healthcare, Health Lyrics and Worldwide Technology who are Newsday show sponsors for investing in our mission to develop the next generation of health IT leaders. We set a goal for our show. And one of those goals for [00:00:30] this year is to grow our YouTube followers. We have about 600 plus followers today on our YouTube channel. Why you might ask? Because not only do we produce this show in video format but we also produce four short video clips from each show that we do. If you subscribe, you’ll be notified when they go live. We produced those clips just for you the busy health IT professionals. So go ahead and check that out. We also launched Today in Health IT. A weekday daily show that is on todayinhealth [00:01:00] it.com. We look at one story each day and try to keep it to about 10 minutes or less. So it’s really digestible. This is a great way for you to stay current. It’s a great way for your team to stay current. In fact, if I were a CIO today, I would have all my staff listening to Today in Health IT so we could discuss it. You know, agree with the content, disagree with the content it is still a great way to get the conversation started. So check that out as well.  

[00:01:24] I ran into someone and they were asking me about my show. They are a new [00:01:30] masters in health administration student and we started having a conversation and I said you know we’ve recorded about 350 of these shows and he was shocked.  He asked me who I’d spoken with. And I said Oh you know just CEOs of Providence and of Jefferson health. And CIO’s from Cedars Sinai, Mayo Clinic, Cleveland Clinic and  just all these phenomenal organizations, all this phenomenal content. And he was just dumbfounded. He’s like I don’t know how I’m going to find time to listen to all these episodes. I have so [00:02:00] much to learn. And that was such an exciting moment for me to have that conversation with somebody to realize we have built up such a great amount of content that you can learn from and your team can learn from.  And we did the COVID series. We did so many great things. Talked to so many brilliant people who are actively working in healthcare and in health IT addressing the biggest challenges that we have to face. We have all of those out on our website, obviously, and we’ve we put a search in there and makes it very easy to find things. All the stuff is curated [00:02:30] really well. You can go out on a YouTube as well. You can actually pick out some episodes, share it with your team, have a conversation around those things.  So we hope you’ll take advantage of our website, take advantage of our YouTube channel as well. Now onto today’s show. 

[00:02:44] Today, we’re joined by Vik Nagjee CTO extraordinare for Sirius Healthcare. I know that’s not your title but I just wanted to say it. Good morning Vik. Welcome to the show. 

[00:02:52] Vik Nagjee: [00:02:52] Good morning Bill. Thank you. 

[00:02:54] Bill Russell: [00:02:54] Well the reason I say CTO extraordinare is cause I love having these conversations with you cause we get to [00:03:00] nerd out a little bit and and you’re at a different level with the technology than most. So I love, I love these conversations. You know, we’ve run into each other a bunch but this is the first time that it’s just you and I on the line sitting down and having a conversation. What have you been up to these days? 

[00:03:22] Vik Nagjee: [00:03:22] Cloud. Believe it or not. That’s something that I’ve been spending most of my energies on these days is, you know, [00:03:30] healthcare organizations are starting now finally to start getting into this rhythm of, hey, we really wants to do cloud. Want to embrace it.

[00:03:38] And so trying to get these organizations sort of on a roadmap and path strategically to get there is really what I’ve been focusing on. Also, I’ve been doing a few other things but that’s mostly what I’ve been focusing. 

[00:03:53] Bill Russell: [00:03:53] Well that’s fantastic. I’m not going to shame anyone because, you know, it’s, I’m just happy [00:04:00] there at the party at this point.

[00:04:01] But my gosh, I mean, we were doing some of this in 2012 and when we started doing it, other industries have been doing it for a decade. So that would indicate that healthcare is still running at about a decade behind. 

[00:04:19]Vik Nagjee: [00:04:19] Yeah. I mean that a decade behind is putting it nicely. Right? I usually say like somewhere 25 and 30 years behind but 

[00:04:26] Bill Russell: [00:04:26] Is that, is that just because of the complexity of the [00:04:30] operation, the workflow, the data, the systems and you know it’s not easy to move all these moving parts. Is that why we still maintain about about a decade  behind?  I have my theory. So I’m curious what yours are.

[00:04:46] Vik Nagjee: [00:04:46] Yeah. I think that there’s a bunch of things. I think it’s very incestuous. You know the applications are all foundational AKA, you know, older generation applications that were typically built fit for [00:05:00] purpose for specific things. They were not born in the cloud era. They are very, they require very specific care and feeding.

[00:05:09] And then you couple operations onto that. So you, the organization has grown in maturity over the years by creating the best in class operations and day two operations that they, can given the circumstances. So decoupling that in getting into a cloud operating model just for the day two operations pieces is like a huge lift.

[00:05:29] Right. [00:05:30] And then you start thinking about how do I actually take and do some. Like you can’t just take an application and you know, lift and shift it. I mean you can, it would be a really bad idea to do that from a cost and you know, scalability and performance standpoint but just in general like these applications were not created for the cloud.

[00:05:52] And the operational models that helped organizations have weren’t born in the cloud. So there’s two [00:06:00] big things that stand in the way. So the idea is like how do you actually start taking advantage of things in the cloud to get you flexibility? And also demonstrate that if you do this in the correct way, you will actually come out ahead both financially and from an agility standpoint.

[00:06:18] So you’ll be able to start doing things a lot better, faster, stronger, and start to you know, get back into this whole consumer first thing that everybody’s going after, rather than just focusing on keeping the lights on. So [00:06:30] it’s a journey it’s going to take a long time to do that but we’re on our way.

[00:06:34] Bill Russell: [00:06:34] Yeah. It’s interesting. I think there’s a handful of other things too. One is there’s a veto culture in healthcare, right? You could be running down a path and just have one or two people not be on board with something and it can slow you down for months if not over a year or so on a specific project.

[00:06:53] So that veto culture is very challenging. Very few health systems are top down. I mean, there’s a handful of them [00:07:00] that are pretty top down. And you know, Kaiser is one of those words it’s more top down than most. And you know, so you have that veto culture. I think the, you know, the, I think the complexity is part of it.

[00:07:15] The amount of data, the amount of systems becomes a part of it as well. And then you have, you always have the financials, you know, follow the money where, you know, where who is [00:07:30] incented to make these changes and who’s not incented to make these changes. And there’s very strong incumbents that are not moving very quickly.

[00:07:38] I’ll leave it at that. I’m a little tired today. I I feel like I gave birth last night or as close as I can come to giving birth. I pulled my first all-nighter, I think since college for heaven sake. And so I’m not going to be as sharp as I usually am. W when’s the last time you pulled it all nighter out of curiosity? 

[00:08:01] [00:08:00] Vik Nagjee: [00:08:01] It’s been awhile. I think that, I think I literally well for work purposes or personal purposes, I guess those are two different things.

[00:08:10]Bill Russell: [00:08:10] How about, how about we stick with work purposes. This is recorded so this is going to go down in posterity I guess. 

[00:08:16] Vik Nagjee: [00:08:16] Yeah no I think that both of those were related and combined, I think it was actually March 13. No let’s see. March 15th, 2010. [00:08:30] So that my son was born on the 16th and I just had to get there. I was working in InterSystems at the time, and we were just about to launch this new feature called mirroring which everybody uses these days. For replication purposes, you know Epic is built on the InterSystems cache platform.

[00:08:49] And we were about to launch that and we had our big users group meeting. And of course I couldn’t go cause my wife was due somewhere in that time but I had to prepare all the materials and the presentations and [00:09:00] the press release and everything else. So that’s the last time I believe I pulled you know several all-nighters in a row. So it’s been a while. 

[00:09:08] Bill Russell: [00:09:08] That’s brutal. I, We we, launched our new website last night and we were doing testing into the wee hours of the morning. So you’re looking at somebody who’s going on about 30 minutes of sleep. So this is going to be fun. We’ve got a lot of interesting stories.

[00:09:23] Grand Rounds and Doctor on Demand have merged, Banner Health posted a 19% drop in net income last year, michigan Medicine [00:09:30] is moving forward with a billion dollar hospital. Obviously the big story Amazon Care launched in 50 States for their employees. Bunch of stuff on testing and vaccine. $10 billion for schools for testing, Walmart’s going to launch digital records to COVID-19 vaccine recipients.

[00:09:45] See anything else exciting in there? Vaccine credentials is going to continue to be a hot topic. I, you know, I jokingly say to people that it’s, we’re getting to the point where it’s going to be show me your papers to get on an [00:10:00] airplane and go to events and those kinds of things. And healthcare has not disappointed.

[00:10:04] I’m seeing articles from very reputable people saying essentially that we are going to have to show our papers to do things. But none of that really sets up the conversation I like to have with you. You do have a CTO type background, and I’d like to, I’d like to hit on a few topics with you before we go into the stories.

[00:10:23] Let’s talk IRIS a little bit. What is, what’s the impact of IRIS to [00:10:30] a health system? How should they be looking at that? I mean, it’s a significant change to the backend. On the Epic platform. What are you seeing and what do you think it means? 

[00:10:43] Vik Nagjee: [00:10:43] Yeah, so interestingly enough I was actually at InterSystems when IRS was in its dream infancy state. ,It was there, it was referred to as a code name at the time. IRIS wasn’t really a name yet. So I was part of [00:11:00] a lot of the initial discussions and you know the things that I will tell you is that. Yes, it’s a different platform. It’s built on top of the same engine that Cachet is, was built on.

[00:11:12] It’s better and it’s faster. It’s more scalable. There’s a lot of features that have been added to it. Operationally, InterSystems and Epic have both done a really good job, I think in terms of helping customers [00:11:30] be able to make that switch from cachet to IRS. So think about, you know the, again, coming back to the day two operations, like there’s scripts that folks have, like the database administrators have, the storage folks have, et cetera, that leverage features and functions exposed via APIs inside of Cache.

[00:11:50] Those all need to be updated to reflect now the new command set and the new API. So InterSystems has created sort of a translation tool [00:12:00] to allow folks to be able to port those scripts over, et cetera, you know, those sorts of things. And then, you know, we layer on automation, orchestration on top of that and things become a lot easier to migrate. 

[00:12:12] But here’s where it gets a little bit interesting. Right. The operational model aside, I think it’s about the financial model and what it actually helps you decide to do, which can actually be a good thing or not a good thing. Right. So previously, prior to IRIS, [00:12:30] healthcare organizations that were running on Epic were you know, had multiple choices in terms of the platforms to pick.

[00:12:37] And I’m talking about several years ago. Now there’s not that many choices. So it could be HPUX. It could be Solares right from Sohn. It could be IBM AIX. It could be, you know, there were, there were a bunch of other platforms and systems out there. And you know it’s whittled, it’s been whittled down now, so it’s AIX and red hat on x86 [00:13:00] virtualized on top of VMware are the two choices on premises that that the customers can run, but essentially it was more economical for a client to pick a particular platform and get a platform specific license.

[00:13:13] So it was like, okay, I’m going to run on AIX that’s great. To change from one platform to another was a huge financial lift for the organization. So they would have to pay a relicensing fee, et cetera, et cetera. So there was a lot of financial implications and we’re talking big, big dollars here. We’re not [00:13:30] talking some small, you know, 5% et cetera.

[00:13:33] It was a big one-time fee that you would have to incur to change platforms. When IRIS came along, one of the things that InterSystems did and then they subsequently did this with Epic was they gave their clients the ability to be able to switch platforms for a much lower barrier of entry. So you still have to pay a little bit of a uptake, but that was an uptick for the feature set from Cache to IRIS. So it’s not really a replatforming fee. [00:14:00] It’s a new platform fee if you will. But what that actually allows you to do is it allows you to go down the route of being able to switch platforms if you decide. So what we’re seeing in the industry now is that folks that have been running on IBM power on AIX now for the first time, have the opportunity to consider moving to X86 red hat virtualized on VMware. And there’s a lot of buzz about that. So there’s a lot of people talking about it et cetera. I don’t have statistics in [00:14:30] terms of, you know, how many folks are looking to re-platform. But I do have statistics around when Epic first introduced x86 red hat virtualized on VM ware.

[00:14:41] The number of configurations that were being requested net new by net new customers coming on board starting probably about, so let’s call it seven, eight years ago. I think 95% plus were on that configuration rather than on AIX. So the number of clients that are running on [00:15:00] X86 virtualized on VMware leveraging red hat and VMware for virtualization is significant.

[00:15:07] So people are looking and considering the options to move. So when they do that, the biggest challenge that they then have is to figure out how to take the operational pieces that they have built and all of the resiliency that they built on the power of ha platform, on the power platform and port that over.

[00:15:27] And so that’s where folks are starting to [00:15:30] run into, what does this really mean? How do I build the resiliency? What is my total cost of ownership? Look like? How do I actually go and build out the operational capabilities, et cetera? So that’s where we’re getting into conversations with clients. So it’s not just about replatforming from one to the other, cause there’s technical stuff too.

[00:15:47] Right? You’re going from a big Indian system to a little Indian system. You do have to do a conversion of the actual database. And again InterSystems and Epic makes that very easy to be able to do that. But there’s, you know, those considerations as [00:16:00] well. So I think in sum total, it’s a good thing that’s happening and it gives folks choices but you have to go about it in a methodical fashion.

[00:16:09] Bill Russell: [00:16:09] Well, let me ask you this. Cause it’s interesting. So while we’re, while we’re hanging out here, I decided to get on their website and look at some of the marketing stuff that they have around IRIS and it’s, it looks like a truly cloud-based architecture. [00:16:30] And if you just look at the marketing of it, it looks like Epic has been able to replatform on top of IRIS which is going to give them the ability to do all sorts of things like plug into some of these some of these advanced technologies like like AI in the cloud and machine learning and whatnot. It it takes their game up in terms of data ingestion and automation around those kinds of things.

[00:16:59] It, it, [00:17:00] It again, from an architecture standpoint, it looks like it gives you a ton of flexibility in terms of how you would architect your environment for you know, high availability, disaster recovery, and those kinds of things. And, you know, I’m not asking you, I mean, you’ve obviously worked pretty closely with some of this stuff.

[00:17:19] I’m not asking you to speak out of school, but I’m sort of curious, is it, am I reading this right? Is that the intention? And I realized that the intention and what [00:17:30] actually happens in the real world has sort of a distance between them, but is that the intention that we’re going to replatform by getting on top of IRIS and then Epic is going to be able to do a host of news things on top of that new architecture?

[00:17:48] Vik Nagjee: [00:17:48] So I, the short answer is no. Let me now give you the longer answer 

[00:17:54] Bill Russell: [00:17:54] Are you telling me I’m wrong? 

[00:17:58] Vik Nagjee: [00:17:58] I’m just, I’m just telling you that [00:18:00] there’s a different way to look at it. That’s all. The so let’s back up to Cache. In Cache version five, which was like 2000 and. 2003, 2002, 2003. Right. In our system, somewhere around that time, introduced a whole bunch of features into cache, which was sort of now starting to deviate away from antsy molds [00:18:30] and turn into true InterSystems cache. And since that time, there have been multiple features that have been added to Cache.

[00:18:39] And again, I’m talking about Cache that IRIS and I’ll build on this in a second, that ABEC has determined that they do not want to take advantage of. And so they continue down the very sort of antsy mobs approach for, you know, multiple reasons. And so they’ve not taken advantage of a [00:19:00] lot of these different features. However, what they have taken advantage of and have been really, really good at taking advantage of and pushing the envelope on are the performance, the scalability, the reliability, and the availability.

[00:19:12] So the razz features that cache InterSystems has introduced over the years. This is allowed you know, when I first started at InterSystems in 2008, Epic could scale to probably about on a single server probably about [00:19:30] 12 or 14 cores on a single server. When I left to go back to up they were able to scale up to 256 cores.

[00:19:42] Okay. That, yeah that’s a lot. Right. And that was all on the basis of intense changes that were made to the kernel to the core database, et cetera. And then Epic had to make changes to their application too. So it was kind of like a partnership, right? So we worked very, very closely together.

[00:20:00] [00:19:59] So those features Epic has taken great advantage of let’s fast forward to IRIS. So the same platform continues on IRS and IRS has a whole bunch of additional features like it just rattle off from the website, which reminds me, I need to go and check in on what the features are in IRS because it’s been awhile since I’ve looked at it.

[00:20:18] But essentially the there’s one additional performance and scalability related feature, which will allow Epic to scale even further. And in fact be able to support [00:20:30] larger clients in a more single system architecture than a distributed architecture and that they have to right now. So it’s going to add simplicity for the clients.

[00:20:38] But beyond that, I think that because a significant portion of Epic’s application runs on the client side, You know, it’s about, you know, 50/50, 60/40 something like that server client split if you will. There’s not that many features [00:21:00] that you’re just described that would be applicable to the Epic application despite the fact that IRS makes this available. So short answer was no. Long answer hopefully kind of made sense. 

[00:21:13] Bill Russell: [00:21:13] Yeah, no, that’s interesting. We were on there. I think the platform was called Health Share or something to that effect. Essentially it was the ability to pull in all these disparate data sources 

[00:21:22] Vik Nagjee: [00:21:22] It was Ensemble and then it got renamed to Health Share.

[00:21:25] Bill Russell: [00:21:25] There it is. Ensemble that’s right. And so we were pulling all that data and I would imagine [00:21:30] that platform can really take advantage of IRIS. I would think. 

[00:21:32] Vik Nagjee: [00:21:32] Absolutely. Absolutely. That’s all on IRIS. That was all built on Cache and that was built on IRIS. That platform is incredible. So if you actually look at any of the REOs or any of the HIE’s that exist out there. A vast majority of them around the world, not just in the U S around the world, they, they are powered by Health Share.

[00:21:55] So incredible platform and does some really amazing things. 

[00:22:00] [00:22:00] Bill Russell: [00:22:00] Well, and I think those, I mean, for us, we were looking at it going all right we, in Southern California, we couldn’t employ all the doctors. So we had to create a clinically integrated network across a lot of disparity EHRs. So essentially we had our own internal HIE that was pulling in the data and we had to build quality metrics and performance metrics across a lot of disparate EHRs.

[00:22:24] I would think any organization that’s looking at an M and A type strategy, that makes [00:22:30] sense, but I see a lot of health systems taking the other approach which is to essentially say, all right we’re going to merge and we’re going to get everybody on Epic, or we’re going to get everybody on Cerner or we’re going to get everybody on filling the blank, whatever the system is.

[00:22:43] Not that that’s a bad strategy. I just think the it’s it’s interesting cause you can get to the same level of integration without doing the migration and you really have two camps here. You have the, we’re all going to be on the same EHR and if you can afford it and you can do it you [00:23:00] should do it.

[00:23:01] But then you have this other camp, like the the, Ascensions of the world. Who have essentially said, look, we have a hundred hospitals. They’re all on different EHRs. And even if they’re not on different EHRs, they’re on different builds and different data and whatnot. And so they went the Google route. Which is give all our data to Google.

[00:23:21] And that was highly publicized. I can’t believe they did it kind of stuff but I understand completely why they do it. And I appreciate why they did it. So they gave it to Google. [00:23:30] And then I’ve seen some videos and stuff of the interface they’ve created. Which which overlays onto all these disparity EHRs and gives them a common clinical record across all 100 hospitals.

[00:23:44] And so that’s that’s a different path that some people  might take what’s the benefits or downsides of either of those paths as you, as you see are or is there another path that people are taking? 

[00:23:57] Vik Nagjee: [00:23:57] No. I think those are the [00:24:00] Ascension path that you mentioned is the least prevalent.

[00:24:03] The most prevalent is, you know, we’re gonna, we’re going to bring everybody onto our systems, financial, clinical administrative, et cetera. The timing of which depends on what the most pressing needs are. Right. And just remember, right? Like healthcare organizations on average have about 500 applications, 450 to 500 applications.

[00:24:22] You know, some have a lot more, some have a lot less, but. Give or take, that’s kind of where you end up. So it’s not just about the [00:24:30] EHR. Of course the EHR is the one that gets the most attention, but it’s all a lot of these other applications as well. But yeah, I mean, those are the two approaches and the vast majority of them are trying to figure out how to get everybody onto a single system.

[00:24:43] You know, there’s financial benefits to doing that, of course, so that you don’t have, you know, you’re not paying for multiple systems, et cetera. But it’s all about strategy, right? Like Banner, you mentioned Banner earlier. Banner has a really interesting M and A strategy. So they go out there and they [00:25:00] are super fast.

[00:25:01] They’re super precise. They’re like clinical precision. Surgical precision. They’ll go out there. They’ll acquire somebody. They will have a team of folks descend on that new organization. And within somewhere between 60 and 90 days, everybody’s converted over and everybody’s using Banner systems. Right. And it’s amazing. 

[00:25:20] Now they don’t do that in every single case for the EHR to bring it on this common platform simply because they do different [00:25:30] types of acquisitions, right? So some are just top-line based acquisitions where the patient population isn’t sort of shared across those organizations. So it doesn’t really make sense because you’re never going to have a provider in one organization visit with a patient from the other organization in the prior world. Now it’s like the lines are blurred, right. Everything’s virtual. But in those cases it makes more sense for the ERP system, for the CRM system, for some of the other administrative type systems to combine them but maybe keep the [00:26:00] EHR separate.

[00:26:00] Right. So there’s a few different strategies, but you’re right. Like the Health Share platform is one that has been used very well. You know, for it’s used for integration purposes internally inside of a healthcare organization to, you know, it’s a message bus, right, is what it is and an interface engine, but it’s way more than that.

[00:26:23] And similarly now it’s used for a lot of outside organizations to sort of [00:26:30] share data and bring it in. So yeah. 

[00:26:33] Bill Russell: [00:26:33] And I bring that  up. Cause the big story,obviously the week is Amazon care launching in 50 States for their employees. People not familiar with Amazon Care it’s essentially concierge level service for employees for an employer program. They will come to you in your office.

[00:26:48] They’ll come to you in your home. They will see you virtually first. And they will deliver your meds and all that stuff to your home. So it’s really a concierge program [00:27:00] for employers. They’re going to launch the telehealth portion of that in 50 States. But I want to stay on the brighter side because I think those two camps sort of fall come into play here.

[00:27:10] I think there’s a group of people that are saying yeah, we see it. We get it. That’s what the competition is going to look like in the future. Not the competition for high acuity care. That’s not what Amazon’s going for, but it’s Amazon. It’s CVS. It’s it’s Optum and others that are getting in [00:27:30] between the health systems and the patient and starting to disintermediate and change the decision making matrix of of the of the public at large is  what it’s looking like.

[00:27:45] And there’s two camps, right? So if I’m a CIO or Chief Digital Officer at this point, there’s the one camp is, you know what? My EHR provider is going to give me enough ammunition to combat this. They’re going to give me the digital tools and Epics made [00:28:00] some strides there. You know, their, my chart platform is now extensible and you can break it down into core pieces and build it back up.

[00:28:07] Or you can go with what they have and go out. But that’s just one aspect of it. You have to also have a care anywhere strategy, remote patient monitoring strategy, an IOT strategy, a there’s just a whole host of things that you have to put together. And there’s health system that are saying, look, my EHR provider is going to do that for me.

[00:28:27] And then there’s others. And we see these announcements [00:28:30] come out from time to time where essentially they’re saying, nah, you know what, that’s going to get me part of the way there. And it’s core system for sure. But the digital capabilities that we’re looking for, aren’t let’s just say a core competency for the EHR providers.

[00:28:47] Therefore, we’re going to go to the people who it is more core competency. We’re going to go in the in the cloud provider direction. We’re going to go with Microsoft Azure. We’re going to go into Google and direction. We’re going to go in the Salesforce direction, really bringing [00:29:00] CRM into this equation. And I know get to a question here. Well actually this is the Newsday show. I don’t, I don’t have to get to a question. It’s just you and I chatting about this. I see these two paths and you know, I’ve always been one who recognizes the limitations of both strategies. Of all my strategies so that I can determine what direction I should go in.

[00:29:25] And the limitation of going with the EHR is they may not be able to innovate fast enough. They [00:29:30] have a lot of clients, a lot of demands and they have regulatory burdens that they have to adhere to. And they’re going to have to throw a lot of programmers just at those things let alone the really advancing the patient experience and helping us to build a care or any work on a strategy.

[00:29:47] So that’s the downside of that. The downside of going with the Silicon Valley approach and some, for those who are on the Silicon Valley side, they’re going to feel like I’m blaspheming here, but [00:30:00] they still don’t understand healthcare. They barely understand healthcare. So you end up with solutions that are maybe not as integrated as they should be. Maybe not as coordinated as they should be. You end up with claims that are a little bit. Beyond what they should be claiming at this point. And so you end up with a lot of unknowns when you go down that path of, are we going to be able to connect this and this, are we going to be able to connect this?

[00:30:26] And then you know, if I [00:30:30] put you in a CTO role right now, what direction would you take? How would you build out your digital strategy for a care anywhere kind of a solution to maybe compete against the Amazon care, the CVS and the Optums as they move into your market? 

[00:30:49] Vik Nagjee: [00:30:49] Yeah, man, that’s a good question. And it’s a tricky one, right? Like there’s a lot of, there’s a lot of different ways that this can go but you asked [00:31:00] me very specifically about what I would do and how I would compete. Well, I think it’s coopertition is what is going to win, honestly, in this case. So, you know, just today there was an article and I was actually looking it up  while you were talking.

[00:31:16] You know our good friends over at General Catalyst the VC firm. So Hemant Taneja who I know fairly well, I’ve talked to him several times. I met him when I was out living out in the Valley. He’s a great guy and he did the Livongo thing. [00:31:30] Right. And it’s just, it’s just crazy what he’s done in healthcare.

[00:31:34] So he and his his buddy Glen Tullman got back together and just formed a new company that was just his came out of Stealth today. It’s transcarent is what it’s called. T R A N S C A R E N T. And essentially what it is is they’re using the Livongo playbook and they’re applying it to the employer sponsored healthcare system.

[00:31:57] So they’re going after this whole market where [00:32:00] the employer, you know, a vast majority of some, I don’t know what percentage of insurance out there is employer sponsored, but it’s big. And so they’re going in and they’re trying to say, okay, 

[00:32:12] Bill Russell: [00:32:12] You know even if it’s not big, it’s profitable. 

[00:32:15] Vik Nagjee: [00:32:15] Exactly. It’s big in one way or the other. Right. So what they’re doing is that they’re going in and they’re using this whole Silicon Valley mentality of creating a consumer first application with the consumer at the center. And they’re actually [00:32:30] building a platform. They built and launched a platform that allows employers to provide this to their employees so that the employees can very quickly based on the insurance that they have and the coverage that they have very quickly get connected to a doctor within seconds.

[00:32:48] Get get information on the closest place to get rehabilitation, those sorts of things. And it’s essentially their business model, which is really interesting here is like, and I was [00:33:00] just reading it this morning actually. The business model is that they’re not charging employers on the front end. They’re charging employers, a percentage of what they save by facilitating this sort of access to their employees on the backend. So the reason why I mentioned this as like, you know, There’s a lot of different folks coming at this healthcare quote unquote problem from different  angles.

[00:33:28] So if you [00:33:30] actually look at what Hemant and Glenn are doing that sort of saying, okay, we want to improve the consumer experience, given the existing capabilities and circumstances that the consumers have to go through their spot. You know, they’re, they’re insured by their employer.

[00:33:48] The employer has certain agreements with with healthcare providers. Let’s just consolidate that information. So you don’t have to spend a lot of time figuring it out. Doesn’t that sound a lot [00:34:00] similar to what Amazon is doing in terms of sort of saying, hey, I’m going to give you a very quick access, right?

[00:34:06] So now, if you go from the employer side and you go to the Amazon side, it sounds very, very similar as to what they’re doing. Then there’s this whole other class of folks that are focusing on some very specific things, which I think is really admirable. And I think that optimization is key. So they’re focused on the problem of eliminating waste in healthcare and there’s statistics out there, which I don’t have in front of me that I [00:34:30] actually had done a whole bunch of research on, but it’s amazing as to how much waste there is in healthcare. And the waste is broken down into different categories. JAMA had a bunch of articles that they released that I studied. And I sort of pulled this information out a little while ago. Well one of the categories that is about 20 to 25% of the overall waste is administrative.

[00:34:54] Right. So if you solve the administrative issues that exist in healthcare, the claims, the claim of [00:35:00] rejection, the number of times you have to submit them all the work, you have to do the number of people. You have to have to do the work, et cetera, leveraging technology. I think you’re moving the needle forward. Right? 

[00:35:11] So you’re asking me how I would do it. You know, I think the short answer is, I don’t know. Cause if I knew, I would already be doing it. But I think the longer answer is it’s a blend of these things that are, I think are going to come together and especially as the regulation changes, et cetera, et [00:35:30] cetera, reimbursement models change and so on.

[00:35:34] I think that it’s going to be sort of a mesh or a blend of these things that have to come together to really make a 

[00:35:43] Bill Russell: [00:35:43] Yeah. And I agree with you that it’s a mesh of the two strategies. I also agree that there’s going to be a lot of really interesting partnerships as we move down this path. All right. Here’s what 

[00:35:54] Vik Nagjee: [00:35:54] I hope. I hope that there are partnerships right? I mean, you and I were talking about this a little while ago, [00:36:00] where there’s a lot of folks in healthcare that are exceptionally blinders base, right. They’re super insular. They just want to do their own thing, which whatever, right. No judgment there but in terms of actually moving the needle I think there’s gonna have to be a lot of partnerships.

[00:36:18] If you just look at what even the HSS is doing, right. The public private partnerships that they are actually starting to push is significant. Because if you actually [00:36:30] bring in folks from the private side, the Googles of the world, the Amazons of the world, the Microsofts of the world, heck whoever, right.

[00:36:38] The Sirius is of the world. Right? You bring folks in and and we collaborate and we can actually do something really interesting, but if you kind of go it alone, you’re going to get the same stuff that you have been. 

[00:36:52] Bill Russell: [00:36:52] All right. Let’s touch on some of these stories. And I mean, we’ve got about 10 minutes ago here, but I wanted to hit on some of them.

[00:36:59] So [00:37:00] Michigan Medicine and Banner are both moving forward with building projects. And building projects is as common in healthcare as you can get. I mean they’re just there. They just do it. I, the, you know, how are health systems. If you and I were starting a building project today for a health system, how would we be looking at the room at the ER, at other things [00:37:30] post COVID from a technology perspective?

[00:37:34] Vik Nagjee: [00:37:34] Yeah, that’s really interesting. So there’s this whole new art and science around the patient room of the future patient room next to whatever you want to call it. And it’s not just the room, it’s like everything else in the hospital. Right. Or in the actual physical building. 

[00:37:48] Bill Russell: [00:37:48] So let’s just go basic. I mean, how am, am I going all wireless? No, you’re not going all wireless. You’re still putting cable in there. What kind of cable are you putting in there and how extensive is the cabling that you’re putting [00:38:00] in there? 

[00:38:00]What kind of density are we going to be looking at for, you know, for the wireless and these rooms as well?

[00:38:05] I mean, how many monitors should we be considering? And if we’re building this out for the hospital, should we be considering how we’re going to build this out for a high acuity situation out of the home? 

[00:38:18] Vik Nagjee: [00:38:18] Yeah. The answer to all of the above is yes, in that, you know you’re still going to be limited substantially [00:38:30] by what the physical systems and the applications can pump out or pump in, so to speak. But just in terms of connectivity, you have to be wireless first, right? You have to have so much capability that not only do your clinical applications have the ability to leverage these wireless protocols. But don’t forget about the patients themselves and their visitors. The visitors always get like completely shafted, [00:39:00] right?

[00:39:00] They get stuck on this guest network. That’s like, you know, baud modem speed at this point. And they’re like, you know, I can’t even, I can’t even surf on, you know, Facebook or Twitter or whatever it is without getting dropped 16 times. And that’s a really crappy experience. Right. So I think a lot of those experience-based things have to be built up.

[00:39:20] And then in terms of the technology. I think it’s really about this whole notion of bringing together ambient listening, bringing together sort of automation and [00:39:30] you know like home automation type things where you actually have, you know, control of blinds, control of temperature, et cetera, et cetera. So I think the technology needs are substantial. And that’s why I say that there’s this new art and science

[00:39:43]Bill Russell: [00:39:43] I love pushing on some of these preconceived notions and one of them is that we have to offer a guest network. So, I mean, we’re getting to the point of 5G.

[00:39:53] And if I’m in a major city, I’m going to those 5G players to say, look, build out at our hospital, use us for [00:40:00] towers, all that kind of stuff. Right. So now I have, and there’s fewer people. I have to do this with too. I mean it’s essentially three carriers now that I have to do with and let’s assume I make my hospital, the hub in each one of the markets that I’m in for a 5G network.

[00:40:18] You know, quite frankly, all my systems are meant to be accessed. Anywhere from what, from the home and whatnot, I don’t need them to be on my internal network to do that. It’s really a customer [00:40:30] experience, a customer satisfaction kind of thing. Are we getting closer to the point where we don’t have to offer an internal network, that we could just have an external provider and make sure that we have coverage, maybe a 5G coverage across cause everybody look, everybody has not everybody, but a significant number of people have a phone, have something and could we just, you know, for those who don’t hand them a device, while they’re in the hospital, it’s connecting up to the 5G network? 

[00:41:01] [00:41:00] Vik Nagjee: [00:41:01] Lot of challenges with that. So 5G is amazing. But the infrastructure associated with it and the ubiquity associated with it is still so low that it’s going to be years before it gets mainstream to the point where you can just be like, okay, You know, this is an alternative and we don’t really need to pop up,

[00:41:21]Bill Russell: [00:41:21] Man, Vik you’re crushing my dreams. Oh man. Come on. 

[00:41:26] Vik Nagjee: [00:41:26] And you’re talking about sort of handing people, phones, you know, there’s the whole [00:41:30] logistical issue associated with that? How does it feel? 

[00:41:32] Bill Russell: [00:41:32] No, I wouldn’t hand them a phone. I’d hand them a tablet, I think is what I’d hand them. 

[00:41:37] Vik Nagjee: [00:41:37] So, you know, so that’s thhe,that’s the point. It’s like, there’s so many of these things, but, and then you have to think about rural places. You have to think about places that have, I have a high density of buildings in a short span. So you know, again, it’s like it’s all a density based situation as to how well you can actually get you know, service.

[00:41:56] And then if you have one carrier that you’re [00:42:00] subscribed to, but there’s another carrier that’s providing the 5G capabilities around you that does, you know no good. Right. So, so there’s a lot of, and you could well with a universal Daz instead of sort of a very specific carrier Daz to really make your life and experience a lot better, but then you were sort of shackled to this one particular provider.

[00:42:18] It costs a lot of money. Like they’re not willing to do it for free anymore for good reason, because they found people will actually pay for it. But you know, I, yeah, there’s a lot of challenges, [00:42:30] man. I think that this whole notion of 5G is a really good one. But I think till, till we get a little bit further along, it’s gonna, it’s gonna be awhile.

[00:42:39] Bill Russell: [00:42:39] Wow, man you just crushed my dreams. Although I’ve been saying for a, that keep an eye on 5g. You don’t have to be doing your plans today for it. It’s something that’s down the road. The challenges that these building projects, Hey, we’re building a new tower, those kinds of things. They’re point in time kind of things and you have to make these decisions. Or, [00:43:00] you know, I remember, you know, you go with you know Cat3 cabling, cat5 cabling. Now it’s cat five, cat six, whatever. But you have to, you have to sort of put a a line in the sand because that building, they’re going to start building that building and you have to put all the infrastructure in and it’s kind of painful.

[00:43:19] Cause sometimes you’re putting it in knowing full well that a year from now you’re going to have to upgrade. 

[00:43:24] Vik Nagjee: [00:43:24] Yeah. Yeah. And I, the good news is that a lot of the low and high voltage pieces have [00:43:30] gotten pretty standard. So, you know, I go to cat six, for example, for ethernet. It’s all about the thing that you hang on the wall that then provides to you the capabilities that are, you know, looking forward.

[00:43:43] So then there’s a new standard for BLE low energy Bluetooth. For example, you take an replace your wireless access point or put, you know, a hub around it. That the manufacturer sells. And now all of a sudden you have BLE where you didn’t without making any changes to the plumbing inside [00:44:00] the walls for example. 

[00:44:02] Bill Russell: [00:44:02] Are those projects are the wayfinding projects and the tracking of device projects, are they finally starting to pick up.

[00:44:10] Vik Nagjee: [00:44:10] They are. And again, I think it’s fits it’s fits and starts again. It’s because of the cost associated with it. So if you go the RFID route, for example, that’s expensive because you’re now talking about asset tagging across all of your assets, and then you have to actually upgrade your entire infrastructure to be able to read these these tags, [00:44:30] right? So as folks go through life cycle for buildings and environmental is for, let’s say the low and high voltage is fine but if I have a network refresh coming up, that’s the time to actually budget for any of those sorts of things. So a lot of the net new buildings that are going in already have the capabilities built in and all they have to add in now are the tagging pieces for the assets. So it’s a lot, you know, the lift is a lot [00:45:00] lower than it used to be. 

[00:45:02] Bill Russell: [00:45:02] So BLE is, is now the direction that we see things going. Is that accurate? 

[00:45:09] Vik Nagjee: [00:45:09] So BLE is really, really good for some really innovative things that are coming out from from different countries. Like there was one, when I was at the Cleveland clinic, there was a provider that was trying to pilot this, which was a small bandaid type strip.

[00:45:25] That they could put on you know, under the arm of pediatric patients [00:45:30] and monitor vitals that way so that the nurses didn’t have to come in and wake the pediatric patient up on, on a regular basis. You know how do they come in every couple of hours to check on you and check your vitals? You could just get this via BLE and you’re fine.

[00:45:44] And you know the outcomes, the patient outcomes are so much better cause they weren’t getting disturbed and woken up every two hours. That it was a huge satisfaction thing and a clinical outcome thing, but here’s the challenge, right? The building that this person wanted a pilot in [00:46:00] was had a pediatric ward, but that building didn’t have the capabilities to do BLE.

[00:46:05] It didn’t even have the capabilities to add the BLE sort of a hub on top of the existing wireless access points because it’s wireless access points for three years old. So it required a significant amount of retrofit to actually get there, which is where these new buildings that have. The state of the art to start with can sort of continue forward.

[00:46:25] So a lot of these have BLE to start out with the wireless access points [00:46:30] do and and you know, it’s just a matter of other things starting to take advantage of them. 

[00:46:36]Bill Russell: [00:46:36] We, we did a pilot back in the day. We used to have sort of the old thing where people could work on whatever project they wanted to for a certain amount of their time.

[00:46:44] And some of my staff set up a a BLE pilot, if you will. And they were able to show how you put these, you know, tracking things on these devices and whatnot. They overlaid it or they put a map in the background [00:47:00] overlay these devices, and you can see these devices moving around our floor. It was actually kind of, it was kind of cool.

[00:47:06] And from a, you know, the cost of losing those devices or nurses supporting those devices and that kind of stuff, there’s a serious cost to that. And I was looking at the pilot that they put together and I thought. There’s  real value in that. And it actually the con, because we we were talking at the time about RFID versus something like this, and the cost was significantly less [00:47:30] for something like this.

[00:47:32] But you know, gosh let let’s talk RPA robotic process automation in three minutes or less. What are you hearing out there? I mean, I, it, I think from a Gartner hype cycle standpoint, It feels to me like, you know, we were talking about it talking, but the good thing about healthcare is it’s already gone through the gardener hype cycle by the time it gets to us.

[00:47:58] Right. So we have [00:48:00] some sophisticated RPA tools that are available. Are you seeing conversations and even some pilots out there around RPA at this point? 

[00:48:10] Vik Nagjee: [00:48:10] Yeah. Yeah, we are. And it’s interesting. So the traditional path of least resistance for RPA in healthcare is around claims. Claims processing, claims, adjudication sort of automating any of those activities by reducing, you know, and again, this goes back to the waste reduction. Right? 

[00:48:30] [00:48:30] Bill Russell: [00:48:30] Right. And there’s millions to be had there it’s an unbelievable. 

[00:48:34] Vik Nagjee: [00:48:34] Millions maybe, maybe even billions, who knows. But, but essentially there’s a lot of that that’s happening. And there’s like two or three different players in the, in the space that are, you know, jockeying for a top position at any given point in time.

[00:48:49] So there’s, there’s a lot that’s happening there. The number of organizations that have adopted it is shockingly low. And I think that’s because again, it’s a relatively quote [00:49:00] unquote new thing. Like the cloud is quote unquote, a new thing in healthcare, right. I think it’s going to take a little bit of time for them to, I mean, you know what I’m saying? Right. 

[00:49:08] Bill Russell: [00:49:08] I do know what you’re saying. We’re going to get in trouble here, but it is. I remember when I came in and started talking about cloud and people are like, Oh, slow down there Buck Rogers, where are you going? And I’m like Buck Rogers. Are you kidding me? I mean in 2012 I knew whole companies that were running in the cloud.

[00:49:25] I knew significant fortune 500 companies that have moved their operations into the [00:49:30] cloud. And they were just like, Oh, that’s the future. I’m like, it wasn’t the future in 2012. And. It’s not the future in 2021. It’s now the past. I mean, moving to the cloud, getting that agility, I feel the same about RPA. If you can identify the millions in claims that you location, and we have the case studies, I mean, Daniel Barchi came on and talked to me about it on the show.

[00:49:52] We have the case studies and Daniel’s willing to do Daniel talks about it at chime. And he’s willing to share information with [00:50:00] people who want to implement it in their health systems. Any he raves about how efficient the process has become. It’s there. The use cases are there. We know that they’re there. Why are we, why are we struggling to move this forward? 

[00:50:15] Vik Nagjee: [00:50:15] I don’t know, man. In our shop you know, like there’s a lot of stuff. There’s so many priorities, you know, 

[00:50:23] Bill Russell: [00:50:23] Yeah there’s this pandemic going on. Right, 

[00:50:25] Vik Nagjee: [00:50:25] Exactly. Right. So, so there’s a lot, but I think it will happen. But I think the [00:50:30] other part that’s really interesting is the applicability of if you drop the R out of it, just process automation in general, the ability to apply that to a broad spectrum of things, even on the it side. So this is not just on the clinical or claim side, but even on the it side to help move the needle on some of these other things and initiatives that are very repetitive and time-consuming, that can be automated.

[00:50:59] We’re [00:51:00] able to learn. In fact we’ve been doing quite a few case studies here where we’re starting to learn from different industries that have improved their, it operations by leveraging process automation. How can we apply those to healthcare? So I think that there’s a really good road ahead. I think again, just like everything else. It’s just going to take time. 

[00:51:20] Bill Russell: [00:51:20] Yeah. Hey Vik you didn’t  disappoint. I appreciate your technical background. I think it’s one of the things that is great about having you on the [00:51:30] show and talking through this stuff. So again again thanks for doing this. I look forward to catching up with you again, hopefully sooner rather than later and just keep hitting some of these topics.

[00:51:43]Vik Nagjee: [00:51:43] Yeah, man. Anytime. Thanks.

[00:51:46]Bill Russell: [00:51:46] What a great discussion. If you know someone that might benefit from our channel, from these kinds of discussions, please forward them a note, perhaps your team, your staff. I know if I were a CIO today, I would have every one of my team members listening to this show. It’s [00:52:00] conference level value every week. They can subscribe on our website thisweekhealth.com or they can go wherever you listen to podcasts, Apple, Google, Overcast, which is what I use, Spotify, Stitcher. You name it. We’re out there. They can find us. Go ahead. Subscribe today. Send a note to someone and have them subscribe as well. We want to thank our channel sponsors who are investing in our mission to develop the next generation of health IT leaders. Those are VMware, Hill-Rom, StarBridge Advisers, Aruba and McAfee. Thanks for [00:52:30] listening. That’s all for now.

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