Integrate, Aggregate, and Innovate – Patient Centric Interoperability with John Halamka

John Halamka This Week in Health IT
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As John Halamka transitions personally into the Innovation role as a focus following the Beth Israel-Lahey merger we explore health innovation topics. What is the impact of the new rule, how will we structure, and what models are we seeing for innovation in healthcare.

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Bill Russell:                   00:10                Welcome to this week in health it where we discuss the news information and emerging thought leaders from across the health care industry. My name is Bill Russell, recovering healthcare CIO and creator of this week in health it, a set of podcasts and videos dedicated to training the next generation of health it leaders. This podcast is brought to you by health lyrics, helping you build agile, efficient, and effective health it let’s talk, visit health to schedule your free consultation if you missed it. We did 13, 10 minute interviews from the show, from the himss showroom floor, women in health. IT was sue shade, Anne Weiler shared, results from a Boston University study that showed better outcomes through digital engagement, Joe Petro, CTO of nuance showed us a clinic visit with no keyboard in the room and that’s welcomed. Uh, we talk policy with Aneesh Chopra consumer experience with Andy Crowder from Scripts identity and perimeter with Wes Wright from Imprivata, whole person care with John Glasser and several others. I hope you enjoy these. Check those out on the website. or the youtube channel as well. Our guest today is John Halamka, the Geek doctor. As your book calls you, I’m not calling you names here. Welcome back to the show. John, it’s great to have you.

John Halamka:              01:24                Well, I’m happy to be here. And remember Geek is a term of affection.

Bill Russell:                   01:28                Yes. Two to yes to the technology class. And it absolutely is. So you are really busy at Himss. In fact, we were both there for several days. I didn’t see you once you, I mean it’s 45,000 people. It’s, it’s really spread out. Um, what, what were some of the things that you were a, you were doing while you were down there?

John Halamka:              01:49                Well I had 35 meetings and 12 speaking engagements in two and a half days and I covered 75,000 steps. So you know, people actually said I saw you everywhere. And I said like, how is that? Well, because I was also in several videos that were playing in several places on the floor and then I was in, you know, screens and all the rest. So it was a wonderful experience to actually be in three or four places at once, which is what I’ve always wanted to do. Uh, so what did I see at himss? Uh, so at Himss this year, the theme of course was patient directed data exchange, right? Every himss has a theme. You know, in the past has been big data or cloud. And even last year it was a little block chain. Now, so much this year, this year it’s with Seema Verma and Aneesh and Mike Leavitt talk and Karen DeSalvo talking about some of the ways that the CMS and onc rules are going to empower patients with the claims data and clinical data. You know, really kind of pushing us to them a future where instead of provider, provider data exchange, it’s provider, patient provider data exchange, solving a variety of privacy dilemmas. Of course we also saw quite a lot of APIs and fire and then every other booth, machine learning AI was big. So those are sort of your big three themes this year.

Bill Russell:                   03:13                Big Three themes. Alright. So let’s go back and forth on some of these. So, um, let’s start with, so the federal government really has taken center stage. Literally. I mean they, they took up a lot of space with their announcement dropping it right before the show. Um, uh, happen, there was a lot of talking before about, uh, transparency, data blocking information sharing, uh, a patient centered patient access as you say. And in that keynote what we heard is they’re really trying to restore market forces to an industry. Um, you know, that’s almost consolidating to the point of opoly status. You know, you have, you definitely have it on the payer side. There’s, there’s the payers have really consolidated, now you’re starting to see it on the provider side of which I’ve lived through it and you’re living through it where you’re at. And um, and some would argue on the EHR side as well. So, um, you know, do these, do these uh, rules that have just dropped, do they help us? Uh, really what they were trying to get to is patient centric as you just described, patient centric interoperability, do these rules. obviously, I think we believe that they’re taking us in the right direction. But you know, we, we’ve seen this before where the, the federal government tries to set a floor, but the industry doesn’t react. Will the industry react to this?

John Halamka:              04:33                Right? Well, so let’s look at the CMS rule, right? That’s only 129 pages, much easier to describe. And what it was mostly about was giving us API access to payer databases because although we’ve done a fair amount of Api work, the argonaut project on the provider’s side, the Davinci project on the payer side is novel. And so we saw with blue button 2.0 some medicare data flowing and now in that rule they’re saying, in fact, if you’re Medicare, Medicaid, medicare advantage chip, any of these government funded or subsidized healthcare programs, you really need to offer this payer based claims Api. So will that happen? I think it will. Um, the lift technologically is not that high. And of course with every regulation, this is a notice of proposed rule making. You have to see in the final reg what the penalties and benefits are. One would guess, given the flavor of the current administration, it’ll be more on the penalty than the benefit.

John Halamka:              05:33                Right? I don’t think there’s new budgets for this. Right. So the only concern I have truly about the CMS rule is that state medicaid organizations are traditionally extraordinarily under resourced from an it perspective. And we saw this and I remember back in the Hie, uh, you know, Obama days when you had a lot of state funding for HIEs, and you know, the funding ended up going to the, the consulting firms. It didn’t necessarily result in operational it infrastructure at a state government level. So they would have to watch the state Medicaid side of that. So again, I think CMS fine, you know, we’ll see. Hopefully some notion of enforcement or embarrassment or something. And unless you’re doing it doesn’t seem like too bad a deal. There’s also the ADT provision, which you must exchange, admit discharge transfer data as a patient goes through the system. Then again, totally reasonable, technologically easy for providers to do that. HS7V2 ADT messages are ubiquitous and cheap. I like CMS in general.

Bill Russell:                   06:44                Yeah. So it was interesting to talk to some of the, uh, some of the people in the innovation community and say, you know, does this impact you? And almost to a person it was like, ah, not really. I mean we, we sort of had to figure this out, you know, five years ago or we wouldn’t be in business today. So it’s helpful and, but it’s, it’s not going to dramatically change their, their, their existing business model. Do you think there’s gonna be new business models like you and I are going to get together in a garage that someday they’ll take picture of and say apple, this garage and this is where John and bill started their, you know, their consumer centric application that really transformed healthcare. Do you think that this will spur on the creative energy of the innovation community?

John Halamka:              07:30                I do. And here’s why. So all of this is just foundational data flow. This does not turn data into wisdom. So where are you going to see the innovation is when there are, what are called data stewards that are aggregating this information and then turning it into action. And let’s, let’s just give an example of how that might work. You probably saw two weeks ago, Aetna, cvs, Caremark and apple announced an alliance. Yeah. And the idea with that is at, no, we’ll give every member and Apple Watch. Fine. So they’ll getting data and cvs Caremark is about the service in a data provider. Apple will end up hosting de identified aggregated data and doing machine learning on it to figure out what motivates people to wellness. Because maybe I’m going to totally make this up, right? If you’re a 30 year old, you want a coupon and if you have 40 year old, you don’t want public embarrassment, right. You, you know, your friends finding out you’re lazy. Who knows? Right. And so imagine a set of services that are offered by companies started in garages that are now aggregating a lot of this new data that we’re generating because patients make it flow and then turn that into action. Better healthcare navigation. I think that lots of startups will start doing that.

Bill Russell:                   08:48                Yeah. That’s going to be, that’s going to be exciting. Um, all right. So I actually, I’d like to talk a little bit about a different trend. Um, then some that you talked about. One that we were talking about prior to coming on this show. Um, we were, we were sort of talking about a consolidation in the changing of roles. And one of the things I’ve heard pretty clearly is that, uh, innovation, digital and information are becoming really three roles within the organizations because the roles are so big. That chief information officer is really focused in on the, uh, on the Emr and the data side, the digital officers focusing on the consumer engagement and consumer experience side and the innovation officers really focusing in on, uh, innovation, uh, really trying to look ahead and to spur community of people to innovate around the problems that specific health systems, um, are, are challenged with and are addressing, uh, are.

Bill Russell:                   09:50                So we talked a little bit about this. If you’re willing to share some of your, you know, your, uh, current direction. I think it speaks to that. But I, I’d like to hear your thoughts of, you know, where you see the different roles sort of evolving. Uh, because I heard a lot of this from the floor. I’ve talked to a bunch of CIOs and they’re saying, you know, my role is changing. In fact, your quote from last year, which was our number to quote for the year from the show was the role of the CIO has changed. Totally. And a I’d love, I’d love for you to just talk a little bit about that.

John Halamka:              10:20                Sure. So think about it. And then in 1996,97 timeframe, when I became a CIO, it was about provisioning, compute and storage power and cooling, and then emerged from there. And Oh, security and resilience and disaster recovery. And it went into compliance. Well now it’s what cloud service for Ehr, for email and productivity software for financials. Do I procure? Not Provision, it’s not capex. Opex. So as you say, you know, back then 96,97 I was the CIO, the Cmio, the CSO, the CTO, right. And so you went into the early two thousands where the CIO role starting to split into multiple people in just that realm, but now exactly right. We’re looking at what is the digital experience for the consumer that’s a little bit tangential to keeping the trains running. The Cio might do and then what is the next business model? Isn’t telemedicine telecare?

John Halamka:              11:24                Is it home monitoring in a, what is it? And that’s the innovation. So as we merged Beth Israel and Lahey I and that merger takes effect on March 1st I will end up being that innovation person focused on questions like, you know, does Alexa, Siri, Google home make a difference in say the workflow of healthcare. If an elder can say, I need an appointment with my cardiologist and two weeks, can you make it in the morning? And it just does. Or instead of having people drive to a physical location, you’re triaging based on a machine learning approach and figuring out what can be done virtually and then doing as Kaiser has half of your visits in a virtual fashion. In fact, we moved from building beds to building virtualists clinicians that are sitting in an office like the one you’re in now and doing teleconsultation. All of those are untested business models and they really require a fast failure. It’ll, let’s try it. Let’s see what works. And a CIO probably isn’t into fast failure.

Bill Russell:                   12:34                Yeah. So you’re going to, so in that role, I would expect you’re going to spend a lot more time with uh, innovation partners. You’re going to be talking to, you know, different voice providers out there seeing what innovation they’re doing, but you’re also going to be listening pretty closely to the specific strategies that your new health system is going to be doing and trying to marry those two things. Cause you’re pretty pragmatic. You’re not going to be talking about something that’s 10 years out and you know, waiting for it to come. You’re, you’re really going to be looking at, I would assume innovations sort of layered over over a year or so, I would imagine.

John Halamka:              13:14                Well, so of course people say what’s happening five years from now? It’s like, are kidding me? You know, imagine predicting the Internet in 1993 right? I mean, the worldwide web, I should say. So what I look is six quarters ahead, as you said, it’s very pragmatic. It’s a technology that exists today but just isn’t evenly distributed. Right? So that is, of course we’re seeing ambient listening, being used in homes everywhere, connect your thermostats or your cameras, your doorbell. We’re just not seeing so much of it in healthcare. So it’s not unreasonable to believe that six quarters from now we could have outpatient services running on Alexa or inpatient workflow happening with Siri. So let’s explore those. So as you say, it’s the apples, it’s the googles, it’s the Amazons, see what they’re up to, how it could apply to healthcare as well. These lovely startups run by 27 year olds in their garages that aren’t as cynical as you and I, they don’t actually know what’s impossible and therefore you got to watch what they’re doing. And Israel a fair amount too. There’s a lot of fascinating Israeli companies around telemedicine, telecare, homecare, Internet of things and such that we have to explore it.

Bill Russell:                   14:34                Yeah. So you probably went to a lot of meetings that were non disclosure. I’m going to ask you for like the, what’s the one thing I’ll share? The one thing that I saw that I thought it was really exciting, I’d love for you to share one thing. The one thing I saw was the nuance booth did a complete visit without the computer in there without the keyboard in the room. And you had essentially, you know, a device with the microphones mounted on the wall in the room with a couple of cameras so it could direct the microphones and pick up nonverbal cues. And it was essentially a capturing the entire transcript on one screen. And on the other screen it was actually using machine learning and AI to uh, uh, to write the note and to essentially put that up there so that when the doctor was done they could just approve the note and move on to their next visit. And that’s just something we’ve been talking about for for years that you know, this experience of looking at the back of the head of your doctor is not going to cut it moving forward. So voice uh, gives us a lot of possibility as we’ve discussed. Is there something that you saw that you were excited about?

John Halamka:              15:44                I will take your theme of using natural language processing, AI machine learning to craft a less burdensome clinical experience to even tell you about a larger trend, which is machine learning not going to save us. All right. Gotta be very careful about that. You know, I wouldn’t want to criticize any particular company’s marketing strategy, but the likelihood that Dr. Watson is going to read a thousand articles and treat you tomorrow with no human intervention isn’t happening in the next six quarters. Right? What’s happening in the next six quarters is I can say, oh, I have studied a million patients like bill. And what I know is that I can improve bills, lifestyle. If I make these two or three interventions and I offer these two or three incentives and that kind of thing. The patients in the past informing the care of the patients in the future gets us closer and closer to a personalized medicine approach.

John Halamka:              16:42                We’re already deploying a dozen such projects at Beth Israel deaconess and it’s simple things like how do I schedule the or who’s going to show up to the appointment? How long are you going to be in an inpatient setting? And maybe we can schedule all the events in a Gantt chart and not randomness or how is it that I can figure out for the wellness care that is going to reduce total medical expense and improved quality that I can put you through the right preventative rather than, you know, curative kinds of measures. All these sorts of things we’re doing with existence. 11 petabytes of patient identified data hosted at Amazon web services, Google cloud and other places under baas to figure out the possible and it works. Okay.

Bill Russell:                   17:31                Yeah, it’s interesting. I had a couple of CIOs. Well actually I heard of one major system health CIO say, you know, I still don’t trust the cloud. And I’m like, wow, I just can’t believe. And we’re at this point a, you almost have to trust the cloud for starters and you have to figure out a way to secure that data, secure the transmission and uh, the, uh, protect that data. But there’s just so many possibilities that are available to you. The other thing I heard was, you know, people saying, you know, I see, well, Google had a big presence. Amazon web services has a big premise presence, uh, you know, the Uber and lift. So you saw some of these companies start to come in and they had a larger presence and people are, people were asking me, you know, what’s the practical application of, you know, partnering with Google.

Bill Russell:                   18:18                I’m like, well, you know, quite frankly, just to go back and watch the show with John and I talking about it. And you shared how with that data you were able to, uh, you know, you were able to look at things and then use fire to push, uh, know different things back into the Ehr to bring it back into the workflow. And I think that’s, you know, that’s the role of the CIO now is to say, oh well in partnership with the chief data officer and strategy is to say, all right, we need to tap into machine learning and AI. Yes, it’s not going to solve the world, but it’s, it’s going to be incremental significant, uh, advancements for every health system. So you have to figure out how to tap into it now, be playing with it now, get your wins so that you know, when it does, you know, when that curve starts to really take off and you’re able to do some pretty significant things and you’re, you’re right there at the starting line, I would think.

John Halamka:              19:14                Well, absolutely. So imagine if the EHR, instead of being a dumb database, which is kind of what it is, it’s transactional systems, gets the bills out, keeps you compliant. You were able to do semantic search and say, you know, a month ago I saw somebody with a gallbladder problem, um, what happened to them? Now that would be a useful tool. So when you think about what Google does, sort of it, their core competency is around structured search. So what if you married Google’s technology with EHR technology and suddenly it became a question and answer platform and not a data entry platform.

Bill Russell:                   19:53                Yeah. Do you feel like you’ve, you selected AWS, does that sort of lock you in or are you going to be able to tap into Google as well?

John Halamka:              20:01                Of course, of course we selected everyone. I have data on AWS, I have data on Google cloud platform and with the merger with Lahey presumably will end up with data on as yourand also a, all of my community hospitals, I have five community hospitals. All their data is cloud hosted. Meditech runs in the cloud, right. It happens to be NTT data was their original partner. So the answer is, is that you? It’s right. Problem, right company. I don’t have any exclusive arrangements with anyone.

Bill Russell:                   20:34                Yeah. All right. So, uh, another trend that I sort of picked up on with social determinants of health and health systems, trying to sort of tackle that. And you know, we heard, you know, roughly 80% of outcomes or non medical family history, personal decisions, financial education, housing, those kinds of things. We’ve actually talked about this before, but I wanted to take us in a little different direction and let’s assume that the financial models are aligned. I know that’s a huge assumption. You know, obvious the business model workflow changes that need to happen and adopting a new business model within the health system are important. But I want it to take this and the technology standpoint. And so I wanted to isolate those variables so that we could talk about, um, you know, how a pragmatic CIO would be looking at that. So I’m assuming we need new datasets and the ability to capture data from new sources. Um, we need to be picking up stuff from monitors, patient reported outcomes, and we need to be able to figure out how to, you know, add a, really go through that data, crunch that data and deliver insights to the point of care. So since you’re a pragmatic guy, how would you look at this as a CIO, given that the business model stuff, is that taking care of, you know, are you looking at platform? I assume a platform and where would you go?

John Halamka:              21:51                Right. So you’ve asked a fascinating question. So we have all these new data streams, novel data sources, everything from your fitbit to your sleep monitor in your mattress. You know, Nokia makes one of those. But what do I do with it, right? Do I put it in the EHR? Is it part of the medical legal record? No one really knows. Uh, what if I don’t act on it? Do I get sued? No one really knows. So our approach for the moment, and I just say for the moment is to store the raw telemetry from patient generated health care data and devices in a separate database and then run rules against that separate database. And when we generate an alert or a reminder, then that goes into the medical record. So putting 10,000 normal blood pressures in the medical record pie doesn’t help anybody, but the fact that your blood pressure is significantly higher or lower now than it used to be. Ah, well that’s something we should act on. And a clinician could in fact avoid information overload or alert fatigue if they just said, oh, I get on average two or three of these a day, and they’re all actionable. Yeah. So that’s been our approach at the moment.

Bill Russell:                   23:11                So you’re interesting in that you, you’ve actually coded an Ehr and uh, not something you’re recommending people go out and do today, but one of the things we hear over and over again is, oh, well, you know, eventually the EHR provider, we’ll do this in this kind of, um, let’s just call it a, an era of faster movement within health and health it and health business models. Um, you know, how, how are you thinking about innovation? Are you going to be innovating outside the EHR or I would that you almost have to innovate outside the EHR or you’re going to be tied to their, sort of, their timeline of innovation.

John Halamka:              23:52                And you’re exactly right. So again, EHR is transactional systems. Compliance bills will exist forever, but do I expect the next great innovation is going to be done by an epic or a Cerner or Meditech e works, Athena probably know, right? They’re going to build their good transactional systems, which we all need. They’ll build the fire cds hooks or the Fire Apis for data gets input for which then innovators connect and create value added services that may run in the cloud or on your phone and that’s where the innovation is really going to happen. We’ll call it the apple builds the phone, but the APP store is where the innovation really happens. It’s the APP store for health. We’ll see accelerate over the next six quarters.

Bill Russell:                   24:40                Cool. All right, John, I’ll do what? What other trends, what other trends do you think we should touch on before we close out the show?

John Halamka:              24:49                Sure. We can’t close out a show without mentioning privacy and security. And the reason being that if we’re sharing more data with more people for more purposes and we’re using cloud and we’re using mobile and we’re using Internet of things because Iot actually also means Internet of targets. In effect, we’ve created our attack surface at 10 or a hundred times bigger than it is today. And so you need to put in place the intrusion detection and prevention, the monitoring and in fact probably machine learning driven systems that look for aberrant behavior, not just port 443 has got a lot of data, but the transactional orchestration doesn’t seem to be quiet, right? Radiology images are being sent to the EKG machine. That wouldn’t make a lot of sense. And so I see, as I said, I’m in Israel a fair amount, an explosion of cybersecurity companies with novel technologies to help us build a foundation as our attack surface increases in size.

Bill Russell:                   25:55                So that’s going to be the place where we see, I think the, uh, why I assume the majority of AI and machine learning being applied to healthcare in the, as you say, the, the three, six, nine, 12 month timeframe, um, as opposed to clinical, we’re going to take baby steps, but in security, it’s probably going to be pretty significant I would imagine.

John Halamka:              26:20                Right. So let’s take for example, an imaging device, CT or MRI scanner. I’ll give you a challenge. Go call up GE or Phillips or Siemens or Fuji or whoever and ask them, so what protocols do you use on what ports and what orchestration can I expect? And you know, the answer here ended yet, uh, we don’t know. Right? So there’s no choice but to put in these machine learning services and say, I’ve looked at the last million transactions out of the cts and Mris, I kind of know what to expect. Here’s one that’s weird. That’s the sort of thing you’re going to see this year.

Bill Russell:                   26:57                Yeah. You also talked about the, the, the um, the vectors. I mean the, the vectors are all over the place. I remember data is now, I don’t want to say scattered to the wind, but our data as you mentioned, is everywhere. And do you have to sort of build your neural net, if you will, around all those directions that you’re sending your data.

John Halamka:              27:18                Yeah. And of course there’s no way we could figure out ultimately as we go from business associate to business associate to businesses. So see it how data ultimately gets used, but we can certainly control our borders, right? So that is in my case with a merger, I’ll have 13 hospitals and 450 sites of care. You know, I’ll have to control all the data flows in and out of all those borders and then put in strong policies, business associate agreements and auditing of third parties to help me understand what happens beyond the borders.

Bill Russell:                   27:55                All right, last question around innovation. So a lot of different health systems set up innovation arms. The summer VC, they look like VC. Some looked like just big sandboxes. You have tech starters like uh, Darren’s doing cedars, um, uh, which is incubating small companies. What do you think your innovation arm is going to look like?

John Halamka:              28:15                Sure. So my model’s a bit different and that is, is that I am not an accelerator or an incubator per se. What I do is I find third party companies, whether that’s a Google or an Amazon or a cvs or an innovator in Israel and bring their technologies inside the organization where a team of a dozen clinician engineers, these are folks because it’s, hey, it’s Boston, right? We’re Harvard, MIT trained people. Then dissect those external technologies to look at the art of the possible. So we actually don’t even call it innovation, we call it exploration. And that’s hopefully going to tell us what will work in the next six quarters and not

Bill Russell:                   29:01                so you’re not looking to monetize as much as you’re looking to solve the problems that your health system as.

John Halamka:              29:06                That’s it. It’s all the operational business problems inside the organization using Ip that may start outside of healthcare or start outside of us.

Bill Russell:                   29:16                Fantastic. Well John, as always, thanks for coming on the show. Thank you for coming off the farm and uh, spending some time with us. And I appreciate it. Um, this shows production of this week in health it for more great content and you check out the website or the youtube channel. Easiest way to get there is and please come back every Friday for more news, information and emerging thought with industry influencers. That’s all for now.


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