One of the most important conversations in healthcare is how to handle the increasing pace of change. Agility is required and a pre-requisite is an intentional framework to handle rapid change. Architecture.

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Bill Russell:                   00:01               Hey podcast listeners, thanks for listening. If you’re enjoying this, we can help it. We just want to give you some information on how you can support these conversations to keep them going. This weekend. Health, its goal is to keep you your organization and your employees updated with the emerging thought and trends in the healthcare industry. Through our conversations with healthcare and technology leaders, the best and easiest way you can show your support is to go over to this week in health it on itunes and leave us a review. Also, you can subscribe on Itunes, Google play, or stitcher, or go over to our youtube page and subscribe and hit the notification bell. Again, we really appreciate you spending your valuable time listening to this podcast.

Bill Russell:                   00:51               Welcome to this week in health it where we discussed the news information and emerging thought leaders from across the healthcare industry. This is episode number 17. It’s Friday, May 4th. Today we use the va as a canvas for painting what a health system might accomplish with the right platforms. This podcast is brought to you by health lyrics. Uh, is your health system position to ride the wave of change? We’ve delivered agile, efficient, and cost effective it for healthcare. Get ahead of the wave, says it. Health to schedule your free consultation. My name is Bill Russell, recovering healthcare cio, writer and consultant with the previously mentioned health lyrics. I’m always asking people, you know, who they would like for me to have on the show, who, who’s interesting, who’s doing fun things. And today’s guest is actually the name which comes up the most. I had dinner with some of his compatriots last week in Arizona and they told me not to tell him that, but, uh, it just flat out true. They, they, uh, people say, you know, we want to hear from, uh, for Dale sanders. So today I’m joined by Dale Sanders, president of Technology for health catalysts to hail. Welcome to the show.

Dale Sanders:               01:58               Thanks, Bill. That’s terrible pressure by the way, for now. I don’t know how I live up to that.

Bill Russell:                   02:05               Yeah, it’s funny. I was having dinner with a couple of people at the Scottsdale is to last week. And, and, uh, it turns out they were from health catalyst, we were talking about some things and I said, well, Dale is going to be on the show and you know, he’s one of the most requested. They said, oh, please don’t tell him that.

Dale Sanders:               02:20               That probably came from Jeff. Randy, I’m thinking,

Bill Russell:                   02:25               let me, let me give a little bit of your bio. I, and um, it’s really fascinating. So let’s see, uh, so intermountain healthcare from 1997 to 2005 where you were the chief architect for enterprise data warehouse, which was a pretty big deal because at the time, I think intermountain had a, uh, had their own ehr platform and, and, and really was building things up from the ground up, but founded a healthcare, a healthcare data warehousing association from 2005 to 2009 cio for northwestern university physicians group and chief architect northwestern medical edw from 2009 to 12. You started as a cio for a national, for the National Health System of the Cayman Islands. So did you live in the Cayman Islands?

Dale Sanders:               03:10               Yeah, I did.

Bill Russell:                   03:12               Why was that? What was that like?

Dale Sanders:               03:15               Uh, it was life changing. I mean, you know, of course it’s beautiful for all the reasons that we all would appreciate, right? The, this, I mean, just fantastic people and culture. And we lived on the beach and I was, you know, I swim every morning and uh, but what was really cool is it’s a national health system, uh, you know, an economy that doesn’t have personal income tax or corporate income tax. Well, yeah, they provide guaranteed care for everybody on, in the population and there’s also a private market there. So it was like this little health ecosystem laboratory and I got to work on everything from national policy with the Minister of health and the premier down to, you know, configuring web browsers for physicians. So it was just great.

Bill Russell:                   04:08               So the obvious question is why did you come back? Why it is an island. I mean, it’s pretty remote, so, I mean, does that the reason you came back to do something else?

Dale Sanders:               04:18               Well, my mom was in the later years of her life and um, I just thought to myself, I want to spend time with her while she’s still healthy, so I put a hold on my career and moved back to my hometown in Durango, Colorado and spent time with her and as it turned out it was awesome because she was in great health and two years after I moved back, she passed away in her sleep, in her home that she lived in for 60 years. So it was the best decision ever to move from the Cayman Islands even though it was a little hard to.

Bill Russell:                   04:53               I’ve heard that story. Now, this is tangent, but I’ve heard that story now from a handful of people that put their, uh, make career decisions based on caring for their parents and, um, in those latter years and not a single one have I talked to yet that has regretted that decision. And you’re just another one on that list. So

Dale Sanders:               05:13               yeah, I can’t imagine it. Yeah, I just was wonderful. And you know, uh, I encourage you in every. Not everybody can do it obviously, but here’s just one last comment on this. I really didn’t know how I was going to make a living when I did that. I just cut the cord and said I’m going to figure it out. If I have to know 10 bar and drive a forklift, I will do that. That spend time with her and as it turned out, that’s about the same time that health catalyst kind of got spun up and, but I had no clue that that was going to happen at that time. So, um, yeah,

Bill Russell:                   05:47               thinks things have a way of working out. And then the last piece of information which is relevant for today’s conversation, cio on looking glass, airborne command post, uh, in the US air force. It support for the Reagan, Gorbachev Summit’s of which about, you have so many stories I’d love to go off on, but. Well, we have to get to the show here. So a nuclear threat assessment for the national security agency and start treating each chief architect for Intel corpse integrated logistics data warehouse and cofounder of Information Technology, uh, international and obviously a president for health catalyst. Uh, one of the things we’d like to do is to ask each of our co hosts to give us an idea of what they’re currently working on or what they’re excited about

Dale Sanders:               06:29               the health catalyst century right now, for sure. Um, in the last two years we’ve basically rebuilt the technology at health catalyst, uh, for the most part, almost bulldozed everything we were doing prior to two years ago to the ground and, and, uh, started over. So, uh, this thing that we now call a data operating system, which may sound like a bit of a buzz phrase, but it’s, it’s the term is genuine and it’s purposely intended to convey something different about analytics and workflow application development. Um, so we’re at a lot of fun with that and we’re building applications on top of the data operating system. And, uh, I’m, you know, what I’m trying to be in this vendor space now is kind of the golden rule of vendor, right? I’m trying to be the vendor back to all my colleagues and friends in the industry that I wish we all would have had. Right? And so that’s fun. I’m trying to live up to that. It’s not easy, but that’s, that’s what we’re doing,

Bill Russell:                   07:35               right. And uh, you know, the thing we hear over and over again from health systems is we need to make the data actionable on a data operating system from the presentation I saw, Cameron gave me a presentation on this and a couple others, um, it has its purpose is to make it actionable, to build applications on it, to be able to move it, to be able to, uh, really make it something that can be put to work to improve health and health outcomes. So very well that’s, that’s the extent of what we allow for in terms of a commercial. We give everybody sort of opportunity to talk on those things. So, so, you know, our format is typically we go in the news, then we do some soundbites that we do a social media close instead of doing two stories and going back and forth.

Bill Russell:                   08:23               I wanted to take this opportunity to really delve into platforms. That’s where you’ve lived. It’s where I’ve lived. It’s what a nice job or calls were, supply siders, right where the people who build out the infrastructure that makes these things possible. And uh, I’m going to use a, the va situation as a muse and it’s the same intro I gave two weeks ago when I was talking to a march with the Cleveland Clinic, but at night sort of veered towards, uh, you know, what you would do politically and what would do, you know, as a cio to Sorta, you know, in your first couple of days at the, uh, at the Va, we’re going to take a little different approach of we’re not going to worry about the politics. We’re not going to worry about the culture. We’re just going to talk about, um, if we were building this thing from the ground up, if we were rebuilding it from where it’s at, this is what we would do.

Bill Russell:                   09:16               So let me give a little background for our listeners and then we’ll jump into it. I’m a, so you have the dod, the Coast Guard in the Va. They all have the hr stories. Um, The patients are obviously really important. I mean, these are the people who risked their lives for us, for the freedoms tHat we enjoy. These aRe, uh, these are people that we would all love to serve, uh, to just give back to them. Uh, the situation in each of these is very public, a very political. So the dod has had a, the one of the worst ehr as measUred by surveys. Uh, and so they responded to that and they launched the new ehr, uh, which they call the mhs genesis platform. It’s built on cerner millennium product. And from what we can tell so far, it’s, uh, it’s going pretty well. I’m from time to time, you’ll hear a senator come out, but, uh, we, we understand it’s going really well.

Bill Russell:                   10:11               Uh, the coast guard has a, had a failed ehr implementation on epic for whatever reason could be change management and, you know, whatever, whatever the cause is, they hit the reset button. They chose to latch onto the dod project, uh, because they believe that the requirements are the same. So the va, this is where we’re at now. So the va has vista built on top of cprs. They recently did a no bid contract that was given to cerner millennium to replace vista. Very public, very controversial. One more piece of information is, um, you know, the va actually was a pioneer in this data record space. People don’t remember that, but, um, you know, back in 2008 when only eight percent of our systems were on an, had an electronic medical record. The va was a leader and, and they had stories on 60 minutes and abc and others that highlighted this, this new movement where we were going to be able to reduce medical errors and a more effective treatments and higher customer sat because, uh, the veterans we’re moving from location to location in the medical record was following them.

Bill Russell:                   11:17               So they, they sort of lead us into this, but for whatever reason, now it’s a, you know, it’s aged a little bit. It doesn’t plug and play real well with the rest of the house. Whatever the rationale is that decided to replace it. So let’s get started on thIs again. We’re going gonna. So we’re going to take the va’s a backdrop and um, you know, let’s, let’s start with our thinking. So how do you think about this? What, what, what should a health system prioritize in terms of the, uh, the infrastructure, both data, infrastructure, you name it, uh, and how should they think about their ehr? Uh, you know, before we make any ehr decision, how should they be thinking? Should they be thinking about, uh, you know, with things like agility, security, what things are we trying to accomplish?

Dale Sanders:               12:11               Well, I mean, to me, I’d be thinking about agility and personalization. You know, one of the concerns I’ve always had about ehr is that they know that it’s a monolithic. I mean, frankly all ehr is this included, are built on pretty old technologies that were never envisioned to be as agile as the modern software engineering data engineering platforms that we have today. So they’re hard to change their hard to modify their certainly hard to extend and uh, and, and so that’s one bias I’ve always had. And I think that bias is shared by a lot of folks, right? I don’t think many people would argue against that, but the other thing that’s always bothered me and you know, clinicians routinely reminded me of this in the trenches of care, is that the, the, it’s too generic, right? Most ehr is tend to reflect sort of a primary care, general internal medicine kind of paradigm.

Dale Sanders:               13:09               And then we twisted and turned it, but baling wire and duct tape on it for specialties and other more personalized uses including patients and uh, you know, at the same time then the rest of the world, I was hold up, you know, my, my iphone is on a platform I have somewhere in the neighborhood of 150 to 160 applications on this. Some of them overlap a little bit, but no single vendor dominates the way I interact with the platform. The platform is dominated by apple for sure. But the apps gives me the freedom to choose what I want and interact as I want. And that’s the paradigm of society in general that we have to drive healthcare towards. So a platform of data and infrastructure, but flexible, agile, personalized applications on top of that data.

Bill Russell:                   14:03               Right? So if you’re a cardiologist, you’re, if you’re on a platform, a cardiologists would see one thing of primary care, not, not necessarily different data, but a different representation of the data based on what, what makes a platform and platform.

Dale Sanders:               14:20               Uh, that’s a good question. I like that. Um, for me in the way that I’ve approached the data operating system, and by the way I’m not plugging health catalyst today here for is I absolutely, it makes me awkward to even pretend or fake that I’m plugging health catalysts when I’m advocating today is things that I think everybody should be doing, including the traditional ehr vendors. They need to have something that looks more like this architecture that we’re calling the data operating system. And so for me, if you look at the traditional technology stack, it starts down at hardware operating system and the application layer. The thing that we’ve overlooked and especially in healthcare is the data layer between the operating system and the application layer. It’s still very, very difficult to work with the data layer in healthcare especially. And so you’ve got software engineering that has progressed on the platform of the public cloud.

Dale Sanders:               15:19               So azure, I mean what we can spin up now in the public cloud is incredible. It’s been commoditized and it’s even better than commoditize the capabilities that you and I never had in our data centers and cio. And we can spend that up into an afternoon. Well now we’ve got these incredible software engineering tools and applications on top of agility that we can spin up applications in angular and d, three at rates, you know, 10 to 100 times faster than anything I could do earlier in my career, but that that layer between the eos and the and the and the application is still, that data layer is still very hard to work with in healthcare. So what we need to do is build out some thing that looks like if this data operating system where we take advantage of the public cloud and all that great hybrid architecture that exists now between sequel and no sequel and and and big data a data lake concepts.

Dale Sanders:               16:13               We take advantage of the software engineering tools that exist on top of it, but the platform now is the data on top of the infrastructure of the public cloud and of course apis on top of that data so that these all these brilliant application developers have a much easier environment to work in. So to me that’s what a platform is. It’s take advantage of the public cloud, move it up to the data layer here at the data and healthcare, and then put apis on top of that data layer, and then then the, the possibilities are almost limitless about the applications you can write on top of the data

Bill Russell:                   16:51               when, when, when I’m asked that question because when I talk about platforms a lot, I talked about platforms to, uh, to my clients and others, but, but what we talked about is the distinction of a platform is, first of all, it’s intentionality. It was designed for others to build on top of it. There you go. Yeah. And so that’s, that’s the intentionality of it. Then the other is layers of abstraction, right? So that there is a data layer, there’s a business logic layer, there’s a presentation layer, uh, there’s a security framework which envelops that whole thing, but all of them are accessible programmatically.

Dale Sanders:               17:25               So,

Bill Russell:                   17:26               so now you hand this to, oh, well actually, you’re walk into any college now and you can put together a, a, you know, a hackathon or whatever they’re called today. And literally you can say, all right, here’s, here’s the api, here’s how you access this data and building on whatever you want, build a web app, build a, a, a mobile app, a use whatever development platform you want to develop. But because of its specific intentionality to enable an ecosystem of developers. And uh, you know, in the case of amazon, it’s enable an ico. It’s a platform because it enables an ecosystem of businesses to resell on it. Uh, it is another platform, um, you know, and I, I just

Dale Sanders:               18:13               probably the classic example, right?

Bill Russell:                   18:16               Yeah, exactly. And uh, and The thing we’ve experienced in the thing we’re talking about here is that the level of agility a health system is able to come up with. So you and I have both experienced this when you have an ehr and you go, all right, we want to do this new thing in the ehr. And we did, we did, you know, about 20 of these a year where we sat down with the ehr provider and we said, we want this custom. We always call them customers and we sit down. Each one costs us out of 250,000 to a million dollars because they’re complex and they’re in, it’s across 16 hospitals, so it’s not a, it’s not a simple thing. Um, whereas if it’s built on a platform, uh, the, the integrity of the data is handled by the data layer, the integrity of the business logic is, and you can start to split those things apart and build very personalized applications for that.

Dale Sanders:               19:12               Yeah.

Bill Russell:                   19:15               Is any ehr provider heading in this direction that you know of,

Dale Sanders:               19:20               you know, there are bits and pieces and of course fire is emerging and we can talk about fire later if you want to, but I just don’t see it. and I, and, and uh, of course that might sound like I’m, we are, we compete against the ehr vendors. But I can tell you that opinion would come from me whether I was competing or not. If I were as cio in healthcare right now, I would be really disturbed by the lack of progress that the ehr providers have made in this. But I would also say this, those platforms, the core of those platforms and dominate the market right now started decades ago and I say all the time, there’s a reason we don’t build code and vb 32 and you know, and cobol and fortran anymore. At some point all tech companies have to bulldoze themselves and re engineer, especially in the old days. I mean, nowadays you can actually evolve a little more gracefully, but I don’t see any evidence that the dominant ehr vendors are bulldozing, taking all that high tech money and all those profits they should be bulldozing that’ll technology and they should be building next generation, the hr around modern silicon valley kinds of concepts. And I don’t see it happening.

Bill Russell:                   20:40               I think I read an article from Jonathan Bush talked about rebuilding based on micro services and those kinds of things. So let’s about what, what are the core technologies if you were redesigned it? So let’s go back to the va. Va has vista and they have a choice of going to millennium. Um, I think it’s, by the way, I think it’s an irrelevant choice. And you know, 15, if you give me $15,000,000,000, my, my response would be, um, I’d, I’d rather stay on vista, I’m sure operational operationally it does what it does and then you can build out a platform. But what things would we, you know, I, I threw out micro services and services. What kinds of things would we look for in a modern ehr from that would define a, a technology platform that,

Dale Sanders:               21:26               that you think would work? Well, I would say let’s give the attributes of the platform and then you can spin off whatever you want to. Including any ehr from the platform, right? Once you have the data, then you’ve got the platform, there’s unlimited use cases with it literally. Right. And so you have to have sort of the abstract layer and the reusable content and logic, the curated data that’s facilitated with api is that’s fundamental in healthcare so that the application doesn’t have to constantly do that. So registries, you know, core things like registries. I’m a metrics value sets, embedded machine learning so that it’s not something that you do as an afterthought, but you can call an api. And you can bind your data to a machine learning ai model without doing externally to the application. It’s a natural part of the, of the data first application.

Dale Sanders:               22:24               Um, it certainly haS to support real time. It has to support batch analytics, right? It has to be microservices based. Um, and there’s a lot of debate about what is microservices really mean. We can talk about that. But what it means is continuous delivery, right? No more of the. I mean, remember back to the days when you had to upgrade an ehr to, uh, it was, uh, it was, uh, thousands of hours initiative that took months and months to plan and execute. And even then it was painful, right? As opposed to the micro services continuous rElease cycle that we see now. So let me comment on that by the way. So this, the data operating system we have right now is microservices based and we’re able to push out updates to our apps and the platform now faster than the cultural ability of health systems is to adapt to it because the culture, you know, our it shops are accustomed to very rigorous configuration control.

Dale Sanders:               23:22               And release schedules at best, it’s like once a month, generally speaking is certainly not daily. So that’s, that’s an interesting thing that’s evolving. Back to the attributes of the platform. The platform has to support the integration of texts discreet and image data. you have to be able to support that and make that a natural part of the data ecosystem. Um, I think I mentioned real time stream it, it has to do that batch analytics, by the way, the it folks want to study this a little more. It’s an easy study. Kappa and lambda architectures in silicon valley are the role model that we should all be following those design patterns or what is what we should all be following.

Bill Russell:                   24:09               Wow. So many directions to go from here. So I’m going to, I’m going to bring it back a little bit because, uh, we just, you know, we’re, we’re plumbers, right? So we’re talking, we’re talking really down into the weeds. So let’s pull it, let’s pull it back a little bit. Um, so we were talking about the va. So the va going to stay with vista and vista is going to be a court, let’s call it a transactional platform, right? So it’s a transactional thing and we’re going to build around it. So the first thing is, you know, cloud dev ops, let’s, let’s get that sort of stood up and then let’s keep that transactional layer there. Um, but then there’s probably another layer. So for our health systems that are watching this saying, well this is a little bit out there, it’s not really out there.

Bill Russell:                   24:59               What we’re talking about is using the traditional I would, they would think of as a traditional enterprise data warEhouse and making that into a and really enabling that platform and then putting a set of apis and the architecture around that that can tap into machine learning, tap into ai, into the cloud and those kinds of things. So this is very practical for, for every health system that’s saying how do we get to the next level in the ehr isn’t moving it, it can’t move fast enough. the, the, the architecture of it will not allow it to, to, to, to move that quickly. They almost have to do the same thing we’re talking about, which is take all the data, move it out, put a new architecture on top of it, and that’s what they’re going to build on. So what does the. What does the traditional cio, what does the architect have a current health system, how should they be thinking about let’s let’s go in this direction. How should they be thinking about tapping into ai and machine learning? Everyone’s talking about it and they’re saying, okay, how do I do this? Do I just move all my stuff to azure and that’s how I’m going to do it?

Dale Sanders:               26:10               Well, the challenge that you have as a cio right now is that you’re. Unless you’re In a forward thinking organization, the loyalty and the commitment to the ehr is significant right now, right? You’ve just spent hundreds of millions, if not billions of dollars on an ehr implementation, and the notion of doing anything else other than that is, is not very appealing right now. Everybody’s a little worn out by it financially and culturally. So what I, what, what I see in the market right now is I’m the hope that the ehr vendors will evolve towards the platform and that they will provide ai and maChine learning capability. I see a lot of hope about that. The other thing that I do see occasionally is, uM, uh, a very unique niche based ai platform being installed in an organization that extract, extract just ehr data out. It might ruin Predictive models for a cardiovascular events or oncology or something like that.

Dale Sanders:               27:18               Uh, And then I see maybe a third tier where it’s kind of a fascinating thing that’s happening. There are some organizations that are, say, we recognize that the ehr on the current trajectory not going to beat our platform needs, so we’re going to build our own. Which is interesting because it’s attractive because the public cloud has made building your own feel more within grasp than ever before. Right? In the old days of building a data warehouse, a data warehouse platform that was a significant infrastructure investment, very unique skills, hard to do. Now that’s been commoditized. But I also draw a parallel between that and the old white box pc, you know, build your own pc, um, uh, you know, 20 years ago when we all thought, you know, why should we buy from ibm and hp when I can go buy all the bits and pieces and build my own pc for a fraction of the cost.

Dale Sanders:               28:15               Nobody does that anymore. Right? And that’s the same thing that’s going to happen. It feels like you can build your own platform now a and sustain it. But the reality is it’s a fool’s errand because you can’t, the platform has been commoditized. The data is the important part in the curation and the management of the data and the logic is the hard part to scale. Uh, so yeah, that I, uh, I, I have this theory that I’m in probably three to five years. I think the dissatisfaction with the current ehr will reach a pain point at which the market demands something else and in an alternative will start to emerge. And the loyalty to those current ehr vendors Is going to be diluted. And I think we’re going to see a bit of a renaissance. I think the second phase of healthcare it renaissance, the real phase is going to happen in about three to five years. That’s my theory.

Bill Russell:                   29:11               I have a summer theory. This ox would be a segue. So my theory is that a cms continues to step up their game in terms of interoperability. Yeah. moving that data around once we are able to have this mantra, free the data, share the data, apply the data and I think that’s what leads to transformation within healthcare and if we can, if we can, uh, and if they continue to push and cms has medicare and medicare is the largest payer, um, and ehr providers are sort of forced into this, opening up that data set and moving it out. I think you’re gonna see probably that same timeframe, three to five years, a really an emergence of renaissance really around the, the experience around outcomes because uh, these, these innovators have been sitting on the sidelines saying, I can’t get the data. And they, they, they go to these various ways of getting it. And then the other thing is it’s really expensive to get it, so yeah, fire becomes the other way that you can get it without paying the exorbitant costs. So where, where do you think we’re at on the fire lifecycle? Obviously it’s an important step and interoperability and it’s, and it’s a huge undertaking. Um, you know, what’s the maturity level of the fire api? What’s the, uh, in terms of working with it, what, what are you finding?

Dale Sanders:               30:33               We like it and you know, I’ve been notoriously critical of hl seven message architecture architectures. They’re so fragile, you know, outdated as, you know from your background, you know, ignoring versus already at architectures. Um, so the fact that the fire kind of emerged out of the rebels and hl seven has been awesome and it’s a, it’s a very solid approach to this problem. And we embrace it. We like it. It’s not moving as quickly of course as we’d like it to because it is consortium based, but it’s moving fast enough. Um, you know, the ehr vendors are now starting to catch on a little bit. The, the leading hr vendors for a long time are dragging their feet because I had a conversation like this back at northwestern and I approached what it was leading the ehr vendors with concepts around services oriented architectures and apis.

Dale Sanders:               31:26               And I described the concept to this leader of the ehr company and their response, I will never forget, they said, well, dale is very interesting, but we see ourselves as more than a database vendor. And so what they thoUght their mindset was, if we open our apis, we diminish the value of our product, which is completely opposite of reality. so that those cultures have changed. Some now we see, you know, the, the, uh, the application, the app stores, you know, coming out of all the leading hr vendors and there’s some progress being made. But the reality is, and I did this in the old days, you can’t wrap modern apis around old architectures and expect a miracle. That’s the bottom line. We did this at intermountain, right when we had help all written on tandem system and tackle and you know, very proprietary languages. And we wrote java based apis around that environment. And so that the writing was java based apis around that environment was interesting and kind of helpful, but it didn’t do what we needed it to do and it didn’t survive. So you can’t just write web services and apis around old architecture and Expected to be tHe miRacle that people expect.

Bill Russell:                   32:45               Yeah, that’s interesting. I know. Love to go on to this conversation, but, uh, it is a 30 minute podcast so I’m going to jump to, um, and actually we’ve, we really could talk about this for.

Dale Sanders:               32:59               Oh yeah,

Bill Russell:                   33:00               it really would be a w. We’re going to move to our soundbite section. I have five questions. It’s just rapid fire. I asked the question, you know, two minute answer on your side and I know that some of these questions are pretty big, so, you know, give it your best shot. So.

Dale Sanders:               33:16               Alright, here we go.

Bill Russell:                   33:18               How will precision medicine changed healthcare in the next three to five years?

Dale Sanders:               33:22               Uh, probably if I had to guess in pharmacogenetics mostly. Um, yeah, I, I mean I have every time I have a lot of faith in genetic precision medicine. I think precision medicine, I’m always thinking about genetics, but um, then along comes epigenetics and the microbiome and we think we understand things and suddenly we don’t, so I think probably pharmacogenetics is the most likely place that it will be a high impact.

Bill Russell:                   33:49               Yeah. I went down to the human longevity, had my genome mapped and it came back with a report and they said, hey, these medications will work for you. These won’t work for you. A kind of thing. And I thought, yeah, that’s the future. That’s what it looks like. It’s very specific, you know, dosages and medication, uh, based on our, our makeup. Uh, question number two, what do you think, what do you think innovation in patient engagement is going to look like?

Dale Sanders:               34:18               Well, I think we’re going to knock the, um, expectations down about patient engagement. We’re already starting to see that in the industry where, um, there’s probably two thirds of patients that don’t really want to be engaged. Now that’s the reality, right? And I’m, I’m kind of one of them, don’t bother me. Really don’t engage me. I’m okay. Just kind of leave me alone.

Bill Russell:                   34:44               Don’t call me. I’ll call you,

Dale Sanders:               34:46               yeah, but when I want, when I have a condition, when I want to be treated, let’s make it safe, let’s make it efficient, let’s make it personalized. So I think we need to shift this notion that we’ve got to constantly engage with patients and expect them to engage. Some folks don’t want to be engaged, some folks can’t engage for various reasons. Um, and we just need to refocus and say, let’s provide really good personalized, safe, efficient care.

Bill Russell:                   35:16               I love that answer. That’s, that’s really interesting. I had not taken that tack before. I will put that in my file that away. What’s the, uh, what’s the biggest barrier to innovation in healthcare today?

Dale Sanders:               35:31               Well, I have two things going on.

Bill Russell:                   35:33               Don’t, don’t get yourself in trouble.

Dale Sanders:               35:34               So interesting. I’m not good at that. Actually. Getting myself in trouble is what I excel at a, it’s certainly the economic environment, the behavioral economics of healthcare and bess, I’m the administrative overhead is a mess. That whole, you know, because we have so much administrative inefficiencies and so many rent seeker economic layers, um, the resources we could use for innovation are constantly on the treadmill of overhead. So we’ve got to drive towards more efficient economic models. We’ve got to disintermediate those inefficient layers and the economic environment to free up money and time for innovation. That’s one thing. Um, reduce the number of measures, right? we have to stop over measuring clinicians. That’s one thing. That’s, you know, that that’s not the fault of the ehr is that makes them so unusable. It’s, we’re, we’re over measuring clinicians and we need to stop that. It’s disheartening to them. But then the other thing that’s holding innovation back frankly is the software. All other industries are differentiating themselves through software and we can’t do it in healthcare.

Bill Russell:                   36:47               I will agree. Uh, what will it take for machine learning ai to take hold within healthcare?

Dale Sanders:               36:54               Well, it started to take hold, but here’s the thing that is a little bit of a fallacy. It ai and machine learning require breadth and depth of data. My background includes time with nsa, pioneers in ai and machine learning, unlimited budgets, and what I learned then is that you can’t just have rows of data. You need to have lots of facts about those rows of data as breadth and depth. We Think about it in healthcare on average, we only see a physician or hospital three times per year that’s equivalent to our digital sampling rate. We have a very, very thin digital sample about us as patients that the healthcare system sees. So when we talk about big data in healthcare, we’re not big data. We collect a 100 megabytes of data per year per patient. That’s nothing. So ai and machine learning will never be fully realized the healthcare until we ran out the full digitization of the patient and we shift the focus of data from the limited data set we have in the ehr to a patient that’s fully censored and collecting data on a seven by 24 basis of some kind. So we’re doing some cool things and interesting things with ai and healthcare here with the data that we have. But the reality is you can’t. You can’t believe the results too much because the data is so thin, you have to be very careful about believing ai and machine learning in healthcare right now. Use the data. So

Bill Russell:                   38:22               that’s interesting. Uh, you know, our experience was that the machines at the bedside provided the best opportunity. There’s a place to start, um, in, you know, in monitoring and analyzing that data in predicting a, uh, you know, events before they were going to happen because you were getting that steady stream.

Dale Sanders:               38:42               Yup. Yup. It’s what I call eastern mutation. The payload which comes from my satellite days in the air force. It seems to mutation the patient.

Bill Russell:                   38:51               Yup. You’re huge in the edw. What’s the future of the edw within healthcare?

Dale Sanders:               38:58               Well, old school batch oriented, you know, read only data warehouses are already outdated. So if you have one of those, you got to figure out how to get off of it. Um, it’s, what it amounts to is that it has to be a platform that looks like these lambda and kappa architectures, which is a single stream of data feeding both workflow and batch analytics. And you can run real time applications and analytics off of that platform. But old school, bachelor rooted edws are over.

Bill Russell:                   39:34               Wow. Well, um, yeah, so this, this half hour goes really fast. Uh, let’s, let’s close out with social media post. I usually try to close out with, you know, something funny this week. I don’t have something funny. I just, that I find interesting. Uh, David Miller, chief executive officer for hci, cio consulting, shared a, a, a gardener, a study that said only one percent of ceos are adopting blockchain for the enterprise. I have theories as to why that is. But uh, that number does not surprise me all that much.

Dale Sanders:               40:10               Yeah, it’s, it’s, it’s overhyped like hadoop was, you know, 10 years ago. Um, it’s interesting. I mean, we’ve looked into it very deeply and it’s fascinating. It’s an I, somebody asked me the other day, shouldn’t we be doing more in blockchain? And I. And my response was, it’s almost too disruptive. It’s almost too disruptive. I mean, technically it has some challenges. It won’t work quite as well as people think it will and in healthcare, but it’s almost too disruptive to adopt in healthcare right now. I think it will be pretty important maybe five to eight years from now.

Bill Russell:                   40:47               Yeah, that’s, that’s it. I only have one client who has me working with them on it and essentially what I’m saying is it feels like five years out and yeah, there’s so many, so many obstacles, but I don’t want to go down that path. Um, so, uh, so what’s your, what’s your approach for the week?

Dale Sanders:               41:08               Uh, my favorite posts of the week came is actually a harvard business review case study that came out of the university of Utah right down the street here in salt lake city. Um, and, and in that, the summary of that story, it was their use of, um, cost data and outcomes data to truly understand the healthcare value equation. So if the healthcare value equation is quality of care over cost of care, right? That’s the value equation. All your care over cost of care, you’ve used at a pretty good job with their own cost accounting system. And in particular, in surgery they’ve done very well, so they know their costs quite precisely in the surgical area of the u of u, but what they’ve also done is very formally measured outcomes associated with the patients and everything that contributed to that particular outcome. So now they bring all their surgeons together with that analytics and they can explore the health Value equation for both individual patients as well as aggregates of patients. So that’s where we, that’s fundamentally, that’s where we need to go with all forms of decision support in healthcare, right friend, it’s the, it’s the, it’s what I call the outcome or cost per unit, the, an outcome achieved. And we got to get away from readmissions as a proxy for outcome, right? It has to be based on promise and promise 16 and functional status and that kind of thing

Bill Russell:                   42:40               to enlist physicians in reducing costs, show them the cost article in the harvard business review. And that’s interesting. I think we always assume that people want the highest quality of care regardless of costs. And that is a, that’s just not the case. And, uh, more and more as we become consumers of, of healthcare, um, you know, quality of life and mental health. I mean, there’S so many things that go into it. I don’t want to spend all my money on healthcare anyway, regardless.

Dale Sanders:               43:12               So that article, it goes into the details. I highly recommend everybody read that article. That’s in general what we need to propagate in all areas beyond surgery.

Bill Russell:                   43:22               That’s awesome. Hey, thanks. Thanks for coming on the show. Um, is there, how can people follow you? Do you, uh, do you have a twitter handle? Do you out on linkedin?

Dale Sanders:               43:31               Yeah, I’m starting to up and down, you know, and that kind of thing. but I’m on my twitter handle is Dr. Sanders everything sets Dr. Sanders is, that’s just my middle initial Dr. Sanders. Uh, and uh, and then I’m on linkedin too and I post out there every once in a while.

Bill Russell:                   43:48               Does that get you in trouble from time to time?

Dale Sanders:               43:50               Well, that doesn’t really, you know, as long as I don’t praCtice medicine, it keePs me safe. But I have to explain to people a lot of times I’m not a dog.

Bill Russell:                   43:57               That’s funny. Awesome. So you could follow me on twitteR at the patient’S cio, my writing on the health erik’s website and I have new article out on health system cio this morning on a data brokers and uh, uh, and that remediation of at data brokers due to the cms announced our cms proposed rule. So see, really see where That goes. Um, don’t forget to follow show at this weekend. Hit and check out the new website this week at [inaudible] dot com. And if you like the show, please take a few seconds and give us a review on and google play. And as always, we’re now up over 100 videos on our youtube channel this week in health you can check those out and, uh, please come back every friday for more news commentary information

Speaker 3:                    44:44               from industry influencer. That’s, uh, that’s all for now.


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