November 13, 2020

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November 13, 2020: It’s been about a decade since the passing of the HITECH Act when we as a country decided to invest many billions of dollars into our health IT infrastructure. So it’s the perfect time to look back and see how things are going. Bob Rudin of the Rand Corporation, a nonprofit think tank, shares their research. The working paper is called “Optimizing Health IT to Improve Health System  Performance.” They interviewed executives from 24 health systems around the country. We see all kinds of efficiencies in every industry, why isn’t it happening in healthcare? What’s going on? What’s the problem? Are we getting value from all the new technology? If not, why not? How can we do better? What about distribution? How do we get apps out to the masses? How do we get the clinicians to adopt them? And with so many mergers happening, is there a secret sauce?

Key Points:

  • Looking at health IT in the context of health systems and how we’re trying to use it to improve performance [00:05:25] 
  • There’s now industry consensus that it’s better for a health system to be on one electronic health record rather than on more. There’s so many efficiencies you gain from doing that. [00:11:25] 
  • The 10 year foundation has been laid but it was 5 years ago when the 21st Century Cures was signed into law that we really saw the first seeds [00:34:05] 
  • Can we all agree that evidence-based medicine makes the most sense? The answer to that is not always. [00:43:45] 
  • Optimizing health IT to improve health system  performance” 

Optimizing Health IT to Improve Health System Performance – Rand Corporation

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Optimizing Health IT to Improve Health System Performance – Rand Corporation

Episode 328: Transcript – November 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] Today in health IT we have a great conversation with a Senior Information Scientist with the Rand corporation, Bob Rubin, who has just as part of  a group just published the results from a two year study on optimizing health IT to improve health system performance. And we’re going to go in depth into that study, have a great back and forth. I think you’re going to enjoy the show. 

[00:00:26] My name is Bill Russell. Former healthcare, CIO, coach consultant [00:00:30] and creator of This Week in Health IT a set of podcast videos and collaboration events dedicated to developing the next generation of health leaders. Thanks think healthcare for supporting the mission of our show. I really am thankful for what they have done this year supporting every week. so that we’ve been able to expand our services and continue to serve this community with this great content and these great interviews. So a special thanks to Sirius healthcare for their continued support. If you haven’t heard, we have a Clip Notes [00:01:00] referral program. Clip Notes is our email that goes out 24 hours after each episode. And it has a summary, one paragraph summary. It has bullet points of what went on the show and it has one to four video clips. What I’ve been told is this is a great resource. It tells you, it gives you just the, meat of what we talk about on the show.

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[00:02:48] So research was just published on the topic of optimizing health IT to improve health system performance. And today we’re going to explore that research with Bob Ruden Senior Information Scientists with the Rand [00:03:00] Corporation. Welcome to the show, Rob, how you doing? 

[00:03:02] Bob Rudin: [00:03:02] I’m doing great Bill. Thanks for having me. 

[00:03:04] Bill Russell: [00:03:04] I keep going back and forth between Rob and Bob ,it’s Bob. 

[00:03:07] Bob Rudin: [00:03:07] Bob is more common for me. 

[00:03:09] Bill Russell: [00:03:09] Yeah. There you go. I’m excited. I came across this research and I was reading and I thought this is really 

[00:03:16] Bob Rudin: [00:03:16] interesting stuff 

[00:03:18] Bill Russell: [00:03:18] for our listeners and you make some distinctions in the, research, but before we get there I have to establish it. So tell us a little bit about what the Rand corporation is and the work that you guys do. 

[00:03:30] [00:03:30] Bob Rudin: [00:03:30] Sure. Yeah. The Rand corporation is a nonprofit think tank. We are a research organization. We do research in the public interest and we publish lots of stuff. all the stuff. That I work on is in healthcare, but we do a range of different topics. Some people work in the military side of things and, yeah, we’re, we, we do, a whole range of different research. what most relevant for us today is in the, healthcare domain. And for that we do population health, [00:04:00] systems, all kinds of stuff related to that. 

[00:04:03] Bill Russell: [00:04:03] Yeah. So the paper that was just published by you and your colleagues, tell us a little bit about the what’s the origin of, the study that you guys did? 

[00:04:12] Bob Rudin: [00:04:12] Sure. So it’s important for me to mention that this study was funded by the agency for healthcare research and quality. That’s the, it’s a grant that  was awarded to Rand. and so all of us, a large team of people worked on it, including people outside of Rand as well. And [00:04:30] the idea behind this was to get better of the larger project must have a better understanding of health systems. And what I mean by health systems are vertically integrated. So hospitals and clinics, not just, stand alone. like hospitals are standalone clinics, but like this a larger, entity. And we’re specifically interested in that because it’s becoming more common. So as I’m sure you, experienced in, in your time, working, in, this space Bill is like these, systems are [00:05:00] growing. They’re getting bigger. There’s mergers, they’re consolidating, on, the whole. They’re more and more the type of work that if you’re going to go to see someone, as a patient, you’re going to probably see someone who’s affiliated or a member of these larger health systems. So that was the gist of this, large, grant that a series of projects, that was funded by HRQ.

[00:05:22] And this one project in particular was looking at health IT in the context of health systems and how health systems were trying to [00:05:30] use health it to improve their performance. And we talked to help with executives from 24 health systems around the country to try to get a sense for how that’s happening.

[00:05:39] Bill Russell: [00:05:39] So 24 mid-size to large size IDN, integrated delivery networks, essentially, is this who you talk to? 

[00:05:47] Bob Rudin: [00:05:47] Yeah, I would say, we’ve had a few on the smaller side where they had maybe only a couple of hospitals and not too many clinics. and then it ranged all the way from large dozens of [00:06:00] hospitals spanning multiple States. And there was quite a number in between. So we tried to get, a diverse range of health systems in terms of geographical location. We picked four different States and also in terms of size and some other characteristics too. 

[00:06:14] Bill Russell: [00:06:14] So, give us an idea, I’m not as deep into academia and these kinds of studies as and maybe some of our listeners aren’t either. How do you go about collecting the information? Is it predominantly through interviews? 

[00:06:27] Bob Rudin: [00:06:27] It’s all over the map for these studies is that it depends [00:06:30] on your study question. So for this, particular study that we did on health IT everything was drived from interviews with executives. So we tried to basically interview, essentially the whole C-suite CEOs. CMIOs. CEOs  Anyone who has relevant experience in the, it space, we looked at data from them. We interviewed more than a hundred executives, but, we also looked at, in part of this, part of the study, some other studies, which I, happy o to give [00:07:00] references to you or your listeners. We also looked at, some quality measurement data, and I think there was some survey data. There was some survey data as well. So we collect data from all kinds of different places, new secondary data, where we, where it makes sense to it’s, the, type of methods and data it’s all over the map, whatever makes sense for the study.

[00:07:20] Bill Russell: [00:07:20] So, what’s the, hypothesis or what’s driving this. What were you looking to identify with this specific study around optimizing health IT. 

[00:07:30] [00:07:30] Bob Rudin: [00:07:30] For this, we started this study a couple of years ago. And the impetus behind this was that it had been about a decade since the passage of the high-tech act. So about a decade since we, as, as a, country, decided to invest, many billions of dollars in our health IT infrastructure in this country and promote adoption of electronic health records and, and other forms of health it. [00:08:00] And we said now is a good time to look back and understand how things are going. Now from a macro perspective, if you look at the big numbers. It’s hard to see a great impact from all this investment. So we look at the big impact and the big numbers in terms of costs, the costs of healthcare have not gone down and qual by the, best quality measures we have. they still are not where [00:08:30] we’d like them. we still see roughly, on any given quality measure, something like 50, the present, you’re, about half likely to get, that recommended treatment as you are not to get it. Quality is very complicated to measure, but still those are some indicators that suggest we’re not really making huge headway. So we said, if we maybe let’s go in and try to figure out what’s going on, like what, What’s happening. let’s do some qualitative research and try to open up [00:09:00] the box, the black box and see what’s happening inside and say, what you know is if it’s not coming, if we’re not getting this value from these, from this technology, why not?

[00:09:10] And what can we do better? what are the opportunities for making improvement? Because clearly there’s opportunity to make better use of technology in healthcare. And in many other industries, like it’s. You see it in every industry, all kinds of efficiencies happening. What’s why isn’t happening in healthcare? We’ve got technology everywhere now. [00:09:30] What’s the, problem. What is really going on? And what’s the problem. So we, did an in-depth investigation into these, 24 health systems and try to, talk to the leadership and see what we could learn. 

[00:09:45] Bill Russell: [00:09:45] Wow. actually, as you’re talking, I’m writing down, I’m writing down like my hypothesis as to, why we haven’t seen major gains over the last 10 years, but yeah, before 

[00:09:55] Bob Rudin: [00:09:55] I’d love to hear your hypothesis, that would be great

[00:09:59] Bill Russell: [00:09:59] I think we’re [00:10:00] actually, I’m going to. I think I’m going to go there, but first I want to, get some of the findings. So you have, I used some great tables in here and I love the distinction you made of improving the performance of it, as opposed to improving the performance of the system. Give us some idea of some of the findings that you guys identified as you did this work.

[00:10:24] Bob Rudin: [00:10:24] Yeah, first thing that we after we collected all this data and looked at it, we [00:10:30] saw that, things fell into a couple different buckets. And what these health systems were trying to do. One of it was they were just trying to get the foundation. They were just trying to get some real fundamental things in place. I’ll talk about some of those. Then the other thing they were trying to do is once, and this is you have to do one before the other is trying to use the foundation to actually create value. It’s like trying to build a house and then [00:11:00] figure out how to live your life in it. So the first step where they were doing things that, it sounds really basic, but gosh, they took a lot of work. So for example, a lot of the health systems we were talking with, they were still trying to get their whole South health system onto one unified electronic health record.

[00:11:19]This is, and they there’s, I think we can say from this study and I haven’t heard anything to contradict this. There’s now industry consensus. It seems that, [00:11:30] it’s, better to be on for a health system to be on one electronic health record than on more than one. there’s just a lot of efficiencies that you gain from doing that. And, we only found one health system out of the 24. That was not on one that actually was on a separate inpatient and outpatient and was not planning on changing. And we asked them, we’re like, We didn’t know at the time they were the only one everyone else was either in the process of merging or had already [00:12:00] merged.

[00:12:00]And sometimes, they were on separate instances at the same vendor, but they’re in separate instances and they were working on merging instances. So it’s not enough to just be on, they have to be integrated on one platform. So we asked them, we said, why, not? did you have you thought about that? And they said, we. We did think about it, but it took us 10 years to tweak our system, to get it to where it is now. It would just be so painful to have to rip it out and replace it. But they did say looking back, [00:12:30] it would have been good to be on one system. So that’s, one thing we learned, so that.

[00:12:34] And when we can talk about the, more of the foundational in a bit, but once you get the foundation, then it’s a matter of figuring out how to use it to improve value. And that’s things like trying to identify variation care, trying to integrate latest evidence, into practice, through different means and make the IT’s configured, so you can enable that. So we found those two, buckets. And I think a lot of people, when they, [00:13:00] when we initially started 10 years ago with high tech, we assumed maybe that we just throw the technology in place and it would create value immediately.

[00:13:08] And I think what we’re seeing is that there is this, foundational level at the beginning, that really is a lot of work for health systems. And once you get that in place, then you can start really doing the stuff that creates value, that where you can start analyzing the data. You can start, finding out where you need to change your processes. So let me tell you I’m that on that [00:13:30] foundational part, there were two things that really jumped out and we didn’t plan on this going in. We didn’t know what we were going to find. We had a few questions in the interview guide, but we ended up talking a huge amount about standardizing data and standardizing processes and workflows and stuff like that.

[00:13:49]For those two things, each of those, we, use standard qualitative methods and coded them and assembled them for each of those codes. There were 200 pages of single space texts [00:14:00] that these executives talked about. There was the most material. Of any other topic that we looked at. So I was, I had to read through all of them, but the message was really clear and that was in order to get value you got to standardize your data because you can’t do analytics on data that’s not standardized. It’s just, so messy. You can do analytics, but it’s a lot less valuable. And then the processes, if everyone’s doing their own processes, it’s hard to make improvements. It’s hard to integrate new, evidence.

[00:14:26]It’s also hard to, even to, give a guarantee to the [00:14:30] patients that they’re going to get the same, experience, no matter where they go in the system. So that was -those two things were, I think by far the most amount of work that, health systems were investing their time into it. And some were much farther along that path than others. 

[00:14:46] Bill Russell: [00:14:46] Yeah. it’s, interesting. It feels like we just got to the starting gate. It just took us 10 years to get to the starting line. And so now we have a yeah, things like standard systems and interoperability, some standard data sets. We’re looking at USCDI. [00:15:00] We’re  looking at FHIR, we’re looking at, a whole bunch of things that are going to open this up, but it took billions and billions of dollars and investment. It took, a fair amount of a fair amount of time and effort. And quite frankly, created some, some challenges for the health system, along the way. And so essentially, improving the performance of IT, part of the frustration, I think with physicians and when [00:15:30] you talk to health systems, as we spent so much money and they, I think they expected once we get the EHR in, everything is going to, all of a sudden take off, but the reality is you just rattled off a whole bunch of those things of, Hey, getting that system in requires us to standardize our processes, to standardize our codes, to standardize our appointment types, to standardize our, and that work ended up being a lot more, I think, than what health systems [00:16:00] anticipated going into, going into the EHR. And then as they finished the, they stopped, they kept growing, And so they merged with somebody else and they’d take on additional systems and they’d merged with somebody else. They take on additional systems. And so it’s not like there’s a beginning and an end date.

[00:16:20] It’s a beginning, get those processes, get the data. And then you’re constantly moving in that direction. I don’t know if [00:16:30] there’s a question in that. I’m just throwing out some of the things that I’ve seen that have really kept us from optimizing in the first 10 years since high tech.  But I think there’s some, promise moving forward as well.

[00:16:44] Bob Rudin: [00:16:44] I think you’re spot on with that. You mentioned some interesting examples. So appointment types, we talked to one health system that they, they said that, in order for them to do analytics and to do appointments, like in a consistent way, they really only needed something like 15 appointment [00:17:00] types.  That’s all they needed that, they needed everything to map to those 15. And that’s that, would capture all the different variation of different types of, of patient appointments when they went in to try to look at it and they found that they had 20,000 right appointment types. and it’s cause they let, they basically had let every clinic, every hospital just decide this on their own and make this up. And they said, go ahead. You, guys figure it out. So everyone. Built it [00:17:30] slightly differently. Lots of overlap. But as you can imagine, if you will try to act as a system and have some kind of analytic view or do some consistent scheduling process where you can schedule, get a, a viewer, you can schedule at any clinic in the same, unified way.

[00:17:47]You can’t do 20 for all those visit types, like you can try mapping them, but then you have to update and keep track of all. It’s just so, they were spending an enormous effort trying to harmonize all that data. 

[00:18:00] [00:18:00] Bill Russell: [00:18:00] And we were trying to roll out a, new digital front door on top of our EHR. I remember it’s just the number of meetings people would go. How hard can this be? Yeah, I just go to open table and I go to the, I said, all right, fine. Then we had that same thing. It started with appointment types. And I was like, all right, there’s 20,000 different appointment types. And we have to narrow that down, by the way, a health system, that’s an awful lot of meetings, an awful lot of governance, an awful lot of, you just to get through it, that those appointment types you think, okay, we’re almost at the [00:18:30] starting line.

[00:18:30] Nope. Not even close, then all of a sudden you have to start to worry about the number of forms, right? Because the number of intake forms that have popped up over the years, And now all of a sudden you’re, sitting down with doctors going, all right, we want to standardize the intake form. Here are the 800 different intake forms that we have. Let’s get it down into a single one. When you get down into a single one and you’re accommodating to everybody, the intake form is so long that it doesn’t feel like an experience that you would get from open [00:19:00] table. It feels more like an experience you would get from, getting ready to take your SATs.

[00:19:05] Yeah, it was it’s I think people underestimate the amount of cleanup. Of how we, the administrative side of how we ran healthcare, and the accommodations we did cause we didn’t see them. We, it didn’t matter to us as long as they collected the right information in a paper form [00:19:30] and then entered some of that stuff into the computer. It didn’t matter. But now all of a sudden, when you’re talking about, systems that are going to touch, multiple geographies, multiple, multiple patient types and those kinds of things. Now, all of a sudden you’re like, Hey, you know what? That is the promise of digital, the promise of digital is that not only can we create those experiences, but the promise is also that we can do the research, right?

[00:19:55] So it’s, we were going to get all this information in there, but let’s just take [00:20:00] oncology. It’s Oh, great. We got all this oncology data. And then when people started to break it out and start to do reporting, they’re like, I can’t do the reporting because. You call something this, and you call something this, and you prescribed something with, 10 tablets of this, and you’ve prescribed things as three tablets of this.

[00:20:20] And it’s actually the exact same thing. and so our analytics team, we’re, just spinning and taking so much time, to clean that up. So I’m sorry. [00:20:30] I’m sorta just telling you why. I think we’re at the, starting gate and that’s essentially what you’re you described? Here’s the two things improving performance in IT was all about getting that EHR, And maybe, even the ERP solutions and, other things. But now we’re starting to see this shift to improving the performance of the system. What is, some of that work look like? 

[00:20:54] Bob Rudin: [00:20:54] I honestly, like most of the systems were, just beginning to get there. They were working on this [00:21:00] foundational stuff. They were working on standardizing the data, standardizing the processes, getting everyone on the same EHR and only just beginning to, so we have a sense of what they were doing in terms of the adding value, but the emphasis that came across really clearly as most of the health systems, even the more advanced ones, in, these, activities were telling us that they were just beginning that journey. So I, but I can talk about some of them. I first wanted to mention though, you mentioned governance, so we didn’t include it in this paper [00:21:30] just because we didn’t have space, but we also learned quite a bit about governance and also some of the- one of the kind of early. Foundational activities is to try to figure out a governance plan.

[00:21:40] Like some of these, health systems we’ve talked to, they were still just trying to figure out how to make decisions. Like they, most decisions were made in an ad hoc and they’d create an ad hoc committee for almost every decision. Whereas some were actually pretty far down the line in terms of having very structured processes for governance. So that’s, [00:22:00] a whole other, dimension, which we didn’t even include in this paper, but we’re thinking about including, and maybe a future paper. Yeah, go ahead. 

[00:22:08] Bill Russell: [00:22:08] No, trust me. I went, when we went to roll out the portal, I had to talk to, five different boards and each board wanted to speak into the user interface, into the data elements and to everything that we were doing. So we finally got agreement between those five boards to a point, some doctors who were part of a committee that would, essentially, instead of going [00:22:30] back to all five boards, every time we wanted to do a change that they would do that. But. just that process in and of itself, once even, after you get all those doctors to agree and Hey, the portal looks good and we’re a portal to, the, app we were gonna roll out.

[00:22:44] Looks good. you still had to get approval from those five boards before, because they’re not in the state of California, they’re not owned by the health system. They’re part of a foundation model. And I think that’s part of the that’s part of the complaint I came from outside of healthcare. That’s part of the [00:23:00] complexity I didn’t appreciate. It’s just, every system is built a little different. There are, there are joint ventures, there are management agreements. There are a wholly owned subsidiaries. There’s, so many different, there’s so many, I don’t know, personalities and political politics, associated with, rolling out the technology, that I don’t think people recognize is actually, is actually there.

[00:23:27] Bob Rudin: [00:23:27] You’re you’re spot on. And also that plays into what [00:23:30] you observation is like that people’s expectations are that it’s, it would be as simple to use as their, like consumer apps, like open table. You mentioned, that’s if you’re not, if you haven’t built these or have some experience, you initially think, oh yeah, I’ll just adopt some tools, throw them in there and everything will just work just like open table. But, to get that, to work like, I, and I’m not an expert in open table, but they had to get agreement on those, processes, all of the people who would, [00:24:00] all the restaurants, they need to, abide by certain, rules and follow the instructions. And the workflows are not nearly as complicated as they are in healthcare.

[00:24:10]But it, gets at one of, one of our big observations with this is just how inefficient, this is. Like every health system, trying to figure this out on their own, like harmonizing all the data and, figuring out all these processes. Like for the most part, we didn’t see that they were able to learn too many lessons from others. Some had [00:24:30] figured out and were able to standardize and yeah. It certainly wouldn’t be possible to have everything perfectly standardized across the whole healthcare system, but we couldn’t help, but notice that, there was a lot of reinventing the wheel going on these fundamental activities. 

[00:24:43] Bill Russell: [00:24:43] Yeah. So people are starting to work on, essentially improvement, improving the performance of the system. Obviously things usually start with monitoring and providing feedback to the providers. But then we start to move to some more sophisticated things, population health,  implementing [00:25:00] evidence-based procedures. You guys identify some of this stuff, reducing variation of care. You know, these are some of the, some of the initial projects that you were finding. And, just, so everybody’s clear, you did this research over a two-year period, is that right?

[00:25:14] Bob Rudin: [00:25:14] We did. We did. We conducted the 128 interviews, I think, over a, over two year period finished in 2019. So this was before the pandemic, situation might be a little bit of, of different, but I, given the timeframes that people were telling us, [00:25:30] it, was taking, some of them were just beginning to set up an analytics department and the timeframes they were looking at was generally in the five to 10 year timeframe. These are, these are long-term long-term efforts. So I, if I were to guess I wouldn’t guess there’d be that much more advanced advancement in the last, like couple of years, just because things take so long. 

[00:25:54] Bill Russell: [00:25:54] Yeah. And I’ve watched some videos where doctors are trashing [00:26:00] the EHR providers or health it, and those kinds of things. And some of it’s, some of it’s warranted to be honest with you. as I listen to their arguments on some of this stuff, I’m like, yeah, no, I get it. I understand where they’re coming from because for we, we spent 10 years putting a foundation in place and, it didn’t deliver on the promise because of, all the work we had to do to clean up the health systems. But there’s a couple of other things that were pretty basic. One is the [00:26:30] technology. Wasn’t all that great. To be honest with you. just from the get-go these EHR, I had a physician write in a survey that we did within our health system. Hey, 1984, just called they want their technology back. and that’s what it feels like to them when they go into these interfaces.

[00:26:45] They’re like, I haven’t worked on these interfaces since I was in college. this is like WordPerfect 5.1. That I, I feel like I’m worth and, that reference, like just flies over the head of so many people, but we used to have to print by hitting shift F seven. [00:27:00] and now I, sound old, but, but that’s, what they felt like. They felt In almost every other area I can do a Google search, relevant information comes to me. I can find just about everything I want, but when I go into this EHR, I’ve got to dive deep into multiple areas, lots of clicks, try to find things the, the interfaces and intuitive. It wasn’t intuitive.

[00:27:24] It didn’t use new, methods. So the tech held us back, I think to a certain extent, the [00:27:30] practitioners, this is a lot of the stuff was new. I look at some of the, implementations and you go back and you talk to some of the people that were around in those early days. And it really was the wild West. They were trying to figure it out. It’s at one point we had hundreds and hundreds of EHR providers to choose from. And so you chose one, you implemented it three years later, you realized. that provider is not gonna be around. And now all of a sudden the, winners are starting to emerge and you go, okay, I’m going to go in [00:28:00] this direction.

[00:28:00] And then three years later you realize that provider’s not advanced enough. And now all of a sudden it’s down to really a handful. it’s, an Epic, Cerner Meditech, And, seen, maybe a handful of others, all scripts. And, but when we started 10 years ago, that was not obvious, that it was going to be those players. And so to a certain extent you had, you had some, bad, implementations, you had implementations on technology that went away. [00:28:30] That sort of slowed us down. I think the other thing that’s happening now, which people don’t want to talk about? I’m sorry, I’m talking a little bit too much. I usually just ask questions, but this is sparked some, thoughts as I’m listening to you.

[00:28:43]One of the things that’s happening now and people don’t recognize it is when you reduce the number of players in any field. and right now you could really say that the, major players in the EHR, Cerner and Epic, for the most part, the amount of choice goes down the amount of, [00:29:00] masters that they have. If you consider every implementation to be a master that has, needs and requirements, every physician using it has needs and requirements, the pace of innovation goes down because they. They also have the same tech debt that we have in health IT. They also have the same challenges of staying up with the regulatory environment. And now you pile on top of that, not just one health system’s needs, but hundreds of health systems saying, Hey, [00:29:30] we need this, it becomes much harder to, to innovate in the ways that we’re, looking at. So now I need to form a question because I’m an interviewer, not a, pontificator.

[00:29:42] Bob Rudin: [00:29:42] Well, maybe I’ll ask you a question  cause you’re you, bring up this topic of innovation in healthcare, which is, always, a major challenge is how to create the right incentives. For innovation and mine. I don’t think anyone’s really figured that out. right, now there’s a good amount of innovation in the research world. And I, and it might be [00:30:00] that for the foreseeable future, a lot of the, big innovations will grow out of academic medical centers or partnerships between academic medical centers and vendors. that’s how EHRs is we’re in created in the first place they weren’t created in an industry they’re created as a research project, but the, the, question I would ask is, is if, for, to, create these incentives for innovation, some of the hope is that, as we create more, ability to [00:30:30] configure these EHRs and add apps to them, is that going to be enough? if, basically, if you can add an app to these EHRs, will that be enough to Create all kinds of innovation or, will,that just end up being just a little piece and at not be useful? I’d be curious if you have thoughts on that. I actually don’t know the answer to that. 

[00:30:54] Bill Russell: [00:30:54] Yeah, innovation is an interesting thing. And incentives is an interesting thing too, because [00:31:00] you know the incentive for, for me and somebody else to go into my garage, I guess that’s where we used to do coding and whatnot, but, to go into our garage and create an app for healthcare, that’s going to change things, is the market. The market is the incentive, Or at least it is in almost any other industry. When Jeff Bezos got started, it was the market is what drove him. When Google got started, the market drove them. but in healthcare we have perverse incentives. And and we also [00:31:30] have roadblocks. So if I want to develop something that’s going to be used to, let’s say, improve the performance of a health system.

[00:31:38] So my primary buyer is a health system. Then I need access to that EHR data in order to get access to that EHR data. I now have costs. There’s a cost to get access to that EHR data because no one, if somehow through contractually or otherwise, the EHR providers, or at least one specific EHR [00:32:00] provider, has a pretty significant control over how that information gets accessed and used. and that was before 21st century cures. And before fire, you had to go through them and you had to pay the toll. To get access to that data. And by the way, there’s, almost no way to get it back into the EHR. And so you’re limited in terms of what you can actually build and what you can actually do.

[00:32:24] And so a lot of, a lot of providers have that first roadblock. The second is a distribution. How am I [00:32:30] going to get it? Out to the masses. How am I going to get this app out to the masses? And I know this because we developed a, we had an innovation arm and we developed some apps and, all right, so now you’re going to try and get it out there. You can try to go sell one by one In which case you have to have a pretty effective sales organization, but if you’re a startup and you’re trying to ramp something up, you want a model like an app store. Oh, they have an app store. That’s great. So let’s utilize their app store and let’s get it out there.

[00:32:54] Now, all of a sudden. You, start to read the contract that comes with the, getting into the app [00:33:00] store and you realize, Oh, wait a minute. If I do this, I’m essentially signing away the rights to my intellectual property. I’m signing away, just that I’m signing away, essentially my organization, anything that we’ve done, just so I can get access to that market. And by the way, my choices are sign away my intellectual property or don’t get access to that market. And they’re just it’s perverse incentives. And so now they come out with 21st century cure. [00:33:30] And this is by the way, the only way I think you can break it because, it is now either provider led or EHR led.

[00:33:37] And so now what you need is the only thing that can break the monopoly is the federal government. And so we have bipartisan legislation that comes through, which is 21st century cures, which establishes, essentially, information blocking rules and those kinds of things. So now. you can’t necessarily get the information back into the EHR, but you can start to get parts of it out [00:34:00] through fire, and now you can start to be creative. And so we talked about this 10 year, foundation being laid, but I will tell you that it was really five years ago when 21st century cures was, signed into, into law that we saw the, The seed, if you will, of, where innovation is going to go next. And by the way, it’s taken five years just to get to the starting line of this, because at every turn they say, okay, here’s the, let’s get the, [00:34:30] let’s get the rules to fine.

[00:34:31] Let’s get agreement on the rules. You get pushback. Because to a certain extent there’s protection, of there’s protection of markets and there’s protection of revenue and those kinds of things, not only from the health systems who believe that if I have your data as a patient, there’s you have more proclivity to come to my health system, but also on the EHR provider side, they don’t want to make it easy for you to get the data out, because if they make it easy for you to get. Data out now, all of a sudden, [00:35:00] instead of them creating, the next, what they would call a module to their EHR, you have really the entire innovation community, not only Silicon Valley, but the entire innovation community in every university, the system across the country, even across the world, looking at this and, a couple of, a couple of people with, a team of three or four people, could.

[00:35:25] No, get together on a weekend and start to really piece together some really [00:35:30] interesting, solutions. And, but, not only that you have, you have, drive in 21st century chores towards, towards standardizing the data as well. So this is where USDI comes in. And, the common data interface and star is going to define things, but also it has given the industry that push to start, standardizing the data and to define, define those common [00:36:00] data sets. So you can have someone like Mayo and Cleveland. And Cedars and Providence get together and say, Hey, let’s define a dataset around oncology that, that researchers can use and that, and that, innovators can use in those kinds of things. And as they do that and submit that work that could become the de facto standard for and around the oncology dataset.

[00:36:24] And so I think we’ve now started to create market looking and market feeling [00:36:30] incentives for people to innovate. That was probably a longer answer to the question than you anticipated. 

[00:36:36] Bob Rudin: [00:36:36] Yeah. I hope it happens like in that case, that would, help also with some of this reinventing the wheel, Like where everyone’s trying to, look at their own health system and try to harmonize the data. If they can just harmonize it to a standard reference model, that’s pretty well defined then that’s a lot, easier than having all of them just make up their own [00:37:00] individually.

[00:37:00] And then, worry about, have it not make it, then worry if it’s not interoperable with some external standard. I, worry when I, so that’s the data side of it. When I think about that. The process side of it. I think it’s might be even more messy. This, is a, another kind of open question is, across, healthcare, there’s always going to be some variation in processes. There’s different types of professionals who do slum with different types of things. but that, when you have different processes that makes it hard to create [00:37:30] applications. cause every, everyone has a different workflow, right? A lot of the EHR vendors, they require the health systems themselves to create the flow sheets and figure it out and so it’s not just buying the, an EHR, it’s buying like a, the rudiments of, of, the things that they have to then configure and spend years and years figuring out how to customize well, if, there was a, bit more, standardization of processes, then that process that, [00:38:00] like setting up an EHR might become a lot, a bit more straightforward, that’s a question that I don’t think honestly, has been studied that well, is, is all this variation and process? Is that just, is it mostly idiosyncratic or does it, is it there for a good reason? and, I’m, curious to know what you think about that from your experience. 

[00:38:20] Bill Russell: [00:38:20] It’s, interesting when we look at these mergers, when I talk to people about the mergers, I’ll say, why did you guys decide to choose that partner? And they’ll say, [00:38:30] their, their clinical processes, their clinical workflows is their secret sauce. So when I partner with this academic medical center or when I merged with this academic medical center, and when I agree to use their, community connect, port, the system and those kinds of things, one of the reasons is the workflows and the, the clinical stops and other things that’s all integrated into the technology. It now becomes the technology becomes [00:39:00] how you become a partner to a major academic medical center and take advantage of all the things that they have. And to be honest with you, I’m not sure the smaller systems have the wherewithal to keep up anymore. And I think it’s one of the things that’s going to drive this. This push over time to fewer and fewer larger and larger health systems. And, because I think it is, it, people might say that, Hey, our competitive advantage is, [00:39:30] how we do these workflows and those kinds of things. But the reality is it’s probably.

[00:39:34] Only a competitive advantage for the top 1% for the, Mayos, the Clevelands and the, large academic medical centers across, the country. I keep using Mayo and Cleveland. I should give somebody else some airtime, but, it’s, it’s the top 1% really that have the workflows that should be replicated.

[00:39:52] Bob Rudin: [00:39:52] Yeah. but I, I don’t think they are being replicated very well. so what, we, heard about was, some of the larger health systems [00:40:00] they were saying within their dozens of hospitals and clinics, they were finding all of this variation and the experience of the patient was different. The protocol, the clinical protocols were different. The, the order sets were different usage of the order sets are different. And any, anything related to that? No actual nuts and bolts work that the, staff were doing was that a lot of variation. And they were very explicit and we heard this from pretty much every health system. They wanted it standardized. They wanted the patient experience when they [00:40:30] go into the door in one clinic to be, yeah, it’s a different person. They might have some different clinical judgment, but they wanted the workflows and the processes to be very much the same, no matter where you go, if that name was on there, they wanted consistency.

[00:40:43] And I, know, the real question is if, there is able to do that. If they’re able to make consistency across very diverse environments within these large health systems, maybe there should just be a reference, a national reference for how to do this, rather than [00:41:00] having every health system, try to figure this out on their own. And that’s, kinda one thing we came to it. Maybe this is just America’s way of doing it, where we like to have lot, just let a thousand flowers bloom. Okay. At some point you let the thousand flowers bloom, some of them bloom, and you say, okay, we’re going to take those and use those because they’re the best ones. And I think, it’s time to start getting those best practices. When it comes to work flows, it comes to using these, it. And spreading it around a little bit more than we. 

[00:41:29] Bill Russell: [00:41:29] And the reality [00:41:30] is that I’ll tell you how that happens. It’s the same half dozen companies doing the major employer implementations across the country. So if I went to Philadelphia or Southern California, North Cal taxes, it’s the same six large system integrators that are doing this. And so sometimes that’s the sort of propagates that way. The other way it propagates is through the EHR providers. that they collect that. Although I think people are a little disappointed in that. I think they’re [00:42:00] going to get very prescriptive processes and those kinds of things given to them when they go with a surgeon, EHR provider. but I think they’ve. and not been as, they are prescriptive. Don’t get me wrong, but not as prescriptive as, what some might, might want or might think, I’m reminded as you were talking about that variation, Mark Harrison spoke at, Mark Harrison, CEO of Intermountain spoke at the JP Morgan conference, I think this past year [00:42:30] and, the past year or the year before he had just taken over. So I think it was a year and a half ago he had just taken over and it’s like, how do you follow. somebody who’s done amazing job at Intermountain. Their margins are stupid Morgan conference, so we’re talking financials and performance, that kind of stuff. They just hit on. Also there’s in a lot of different areas and, he decided to address the exact thing you talked about within Intermountain. Who’s widely considered one of the most efficient health systems in the country. And he found [00:43:00] that he, but they’re under his direction. They found tons of variation. And some of which led to adverse outcomes. And what he said is, look, if we’re getting this outcome here, we should get this outcome here. And what they identified was the process difference.

[00:43:16] And following, the standard, or the evidence-based practices and those kinds of things. And again, having sat in these meetings, I know where it goes, the evidence-based practices. You’ll [00:43:30] have people go, Hey, here’s the evidence-based medicine. And if you don’t have a very top down organization, you’ll have physicians that look at you and go, yeah, I’m not doing that. I’ve been practicing for 30 years. That makes no sense to me. I don’t understand. And it’s like it’s evidence-based medicine. Can we all agree that evidence-based medicine makes the most sense? And the answer to that is not always. 

[00:43:54] Bob Rudin: [00:43:54] Yeah. it’s, a change it’s, true. And, all the health systems they have, if some of [00:44:00] the more advanced ones had different strategies to manage that, I, will say we did talk to one health system and they said specifically, one of the drawers that they were trying using one of the,  carrots, they would say, come on, join our health system. We’ll let you do whatever you want. And we’ll, do a little bit marketing will, but you can set everything up. And then now they’re, getting all these requirements, they want to join ACS. They want to do public reporting. [00:44:30] They want to do some more, like evidence-based medicine and they’re, they have built this whole culture of independence. And it’s really hard to do just for the exam. Exact reasons you’re talking about. 

[00:44:44]Bill Russell: [00:44:44] I appreciate this conversation. It really sparks a lot of thoughts in my mind. the, in my minds, I have one mind. So my mind, you know, are you going to be any, you, referenced some other work. Is there any additional work that you guys are going to do on this study or other [00:45:00] studies, around this area?

[00:45:02] Bob Rudin: [00:45:02] There there are some other studies, there’s, some stuff that’s already been published in the, on the health systems, front, and, but in terms of health, it, we may have one more, that, around this governance issue that I. Just need to obviously find the time to write it up. 

[00:45:18] Bill Russell: [00:45:18] What, are you doing? It’s COVID your in here? you should have tons of time. 

[00:45:23] Bob Rudin: [00:45:23] I had tons of time until my, my daughter was born three months ago. That’s 

[00:45:28] Bill Russell: [00:45:28] Congratulations. 

[00:45:29] Bob Rudin: [00:45:29] Thank you. 

[00:45:31] [00:45:30] Bill Russell: [00:45:31] That’s great. So is that the, is the beard like since COVID or since, her birth. 

[00:45:37] Bob Rudin: [00:45:37] It was, since COVID. and, but yeah, it’s been there. It’s been there ever since she was born. So I can’t save it now because Sasha knows me. 

[00:45:46] Bill Russell: [00:45:46] She’ll show you she’ll know you in other ways, I think, but congratulations. That’s fantastic. This is great work. I appreciate it. How can, people find this work? How can they read this? 

[00:46:00] [00:45:59] Bob Rudin: [00:45:59] We issued a press release, so you can see some summary of it. the press release. you can, I don’t think it’s open access, but you can at least see a summary of it. it’s published in this journal, this journal health care. it’s a delivery science and innovation. so if a member, if you’re a member of a, academic institution or healthcare institution, I’m sure they subscribe to it. If not, I, I can help facilitate that. If you just want to email me, honestly, I can to try to get you a copy. 

[00:46:29] Bill Russell: [00:46:29] I’ve [00:46:30] done that. I will tell you, search a Rand corporation, your name, that the title of the study is “Optimizing health IT to improve health system performance” and I think it’s a work in progress. Is that right at the end title? A work in progress? 

[00:46:44] Bob Rudin: [00:46:44] Yeah. Th the paper’s not a work in progress. The paper’s done right. The optimizing health it and health systems. That’s what we’ve found is that work in progress. 

[00:46:54] Bill Russell: [00:46:54] If they search that, I actually downloaded the PDF that they let you. [00:47:00] Download that from the site. And there’s a fee for it. It’s a couple bucks, but if you’re a part of an academic medical center or a university institution, more than likely you have access to the, to the research, Hey Bob, thanks. Thanks for your time. I really appreciate it. 

[00:47:16] Bob Rudin: [00:47:16] Sure thing. It was fun. 

[00:47:17] Bill Russell: [00:47:17] Yeah. And next time you, have a, another one of these studies, shoot me a note and, I’d love to, love to talk through it with you.

[00:47:25] Bob Rudin: [00:47:25] Sounds great. Will do. Thank you. 

[00:47:27] Bill Russell: [00:47:27] That’s all for this week. Don’t forget to [00:47:30] sign up for clip notes, send an email, hit the website. we want to make you in your system more productive, special. Thanks to our channel sponsors, VMware, StarBridge Advisors, Galen Healthcare,  Health Lyrics,Sirius Healthcare, Pro Talent Advisors, HealthNXT and McAfee for choosing to invest in developing the next generation of health leaders. This show is a production of this weekend, off it for more great content. Check out the website this weekhealth.com or the YouTube channel. If you want to support the show best way to do that. Sign up for clip notes, participate in the referral program. send it out to your peers [00:48:00] and let them know that you’re getting value out of the show. please check back every Tuesday, Wednesday, and Friday for more shows. Thanks for listening. That’s all for now.

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