Episode 13 : Disruption or Evolution?

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Intro/Outro:
Welcome to Smart from the Start, presented by Care.ai, the Smart Care Facility platform company and leader in AI and ambient intelligence for healthcare. Join Steve Lieber, former CEO of HIMSS, as he interviews the brightest minds in the health provider space on truly transformative technologies that are modernizing healthcare.

Steve Lieber:
Hello, and welcome to Smart from the Start. I'm your host, Steve Lieber, and it is my pleasure to bring to you a series of conversations with some of the sharpest minds in health information technology. We'll discuss the smart directions healthcare companies and providers are pursuing to create smart care teams. Today, I'm joined by longtime friend, and I dare to say colleague, John Glaser, an individual known by many of you, but let me give you a little brief intro in terms of John's background. John is an Executive-in-Residence at the Harvard Medical School, and previously served in several senior executive roles in both vendor and provider organizations. He is a former Senior Vice President of Population Health at Cerner Corporation, Chief Executive Officer of Siemens Health Services, and Chief Information Officer at Partners Healthcare. John also has a long history in leading the professional associations in the area of health information technology. He was the founding chair of the College of Healthcare Information Management Executives, CHIME, and the past president of the Healthcare Information and Management Systems Society, HIMS, and a former chair of the board of the American Telemedicine Association. John, welcome.

John Glaser:
Thank you. Steve. It's a great pleasure. And you're correct, you and I are long-standing and good colleagues and friends, so it's a pleasure to spend some time with you.

Steve Lieber:
I appreciate that, and really, as I do look back over years, that we don't need to articulate how many. It's been a lot of fun, and you are certainly someone that I always look forward to running into at conferences and other places to tap into your thinking about what's going on, and that's exactly what we're going to do today. What I'd like to start out with is your role as an educator. You've done a lot of speaking in a variety of roles at HIMSS and CHIME conferences, CHIME bootcamps, Wharton, other places where you've been on faculty. So what are you seeing in terms of both the state of education for practicing? So we're not talking on the pure academic side, but on the practicing side. And what are we seeing coming out of the programs today?

John Glaser:
Well, Steve, first of all, I really enjoy education. It's a lot of fun, and particularly at the postgraduate master's level and the executive education level, etc., and so I think I'm having a simple ton ... for a dozen years. And so what you could see is in the 12 years ago, very interested in the electronic health record, what was going on. Meaningful use was here, and now that's yesterday's news for most of these students. They're interested in AI, they're interested in mobile devices, and things like that. So obviously, what you teach and talk about moves as the technology moves, AI was not as big of a topic a dozen years ago as it is now. And when you get into executive education, they've got scar tissue, they've been around the track, they've been in big organizations. They know how politics can be hard, and change can be hard, and so, and they're very action-oriented. So they're much more interested in, well, how do I do this and how do I do that. There's a lot of focus these days, Steve, on digital transformation. What does that mean? How do we do it? Why is it so hard? Why is, why does it fail so often, etc.? So I enjoy helping those people be better, more effective, and more knowledgeable. And I'll give you an example that they had, sometimes organizations think about digital transformation, it's a project that has a beginning and an end, and the answer is there is no end. You will always be transformed, okay? And that's just the kind of insight and understanding that can happen. And obviously, particularly in the Harvard, we, and I think the Zoom technology is better than I would have thought, although not as good as in person, but still, you can get people from across the planet, so in the courses I teach, two-thirds are from outside the US, and so there's a variety of experiences. So the person who's the CEO of a hospital in Mongolia is talking to the person who is a pharmacy rep in the Middle East, and it's interesting how much they learn from each other. So I think as a field moves, the topics move, and as they get more senior and more organizational exposure, they tend to be more focused on practical how to do various things, etc. And I do think you who teach, and I who teach, you can have a broad impact. We've taught in one of my courses 800 people this year. That's good. So I hope they're not screwed up by this process, but nonetheless, that's 800 people are probably going to be more effective than they were before.

Steve Lieber:
Yeah, so one of the things that that I've heard, especially around clinicians, and I would expect in your programs, you're going to have a mix of pure management types as well as clinicians who have an interest in other aspects other than pure clinical practice, is that the expectation that, the technological expectation when they walk into a provider organization, say, is higher today in terms of what they're expecting to find in the way of tools because of how they grew up, is that pretty valid?

John Glaser:
Well, I think that's quite fair. So I mean, in the, when I first began, there was a generation of clinicians who had never really had any exposure to the technology, were suspicious of it, had to be trained about it, viewed it with a bit of apprehension, and dread, etc. And pretty soon after they started using it, their fears were confirmed, you know, you know, yikes, this ... etc. But I think you've got a generation now, I was looking at some data yesterday, the average teenager in the US spends five hours a day on social media on average in games, etc. So they are expected to be useful, they expect it to be easy to use, they expect that it will help in lots of ways, and sometimes they're really quite taken aback when they get into our organizations, and they say, golly, this stuff has been around since the Stone Age, and it's complicated and hard to do. So I do think in the clinicians, the sort of familiarity and expectations are different. The other thing I think Steve has gone on is if you go into the boardroom. When I first began in this field, which is in the mid-80s, as a CIO, boards really didn't have a clue about AI. They didn't grow up with it, they didn't really understand it. It was a, you know, expense every now and then screwed up and caused all kinds of havoc. And now you've got board members who are in their 40s, and they grew up with this stuff. They expect it to be strategically compelling. They know it's hard. So you've got some seasoned, insightful people at the board level that you just really didn't have 30 years ago.

Steve Lieber:
Let this great insight, hadn't really thought about that at the board level. Certainly, we're faced with it daily in terms of our teams and ongoing operations, but from a higher strategic and governance level, you're absolutely right. That generation has changed or is changing as well. You got several things there that I want to unpack. One, you mentioned history in terms of people with clinicians that when we started to install certain things 15, 20 years ago, it didn't quite turn out the way they were expecting, and there was a lot of resistance. Let's start there in terms of what we learned from the EHR implementation process because, I mean, you were very involved in terms of all aspects, from being an installer and a provider organization to being a seller in a company deeply involved in the policy as well, and government regulation and that sort of thing, and advising numerous government officials and administrations. So as we look back, I'm going to believe that we're going to say, yeah, it was all worth it. In fact, it probably was the necessary foundation for us to be able to do what we're doing today, but your take on that, what we went through.

John Glaser:
Well, I think, Steve, it clearly a necessary foundation. I mean, it's hard to, you and I couldn't sit here and say, boy, healthcare would be better off if we all went back to paper. What that would, boy, what a sigh of relief and what an improvement we see, come on. Now, that doesn't mean we don't have a lot of issues with what we have, but nobody would say that with any, really, a straight face here. I think a couple of things have been learned over the years, one of which is the surest way to screw it up is to have the people who are expected to be using the system to believe that they are victims. You're doing this to them. They have no say. They're being dragged along, kicking and screaming. And I don't care who you are, be a doctor, you could be a banker or an auto mechanic, you're not going to like that, period. So the thing you learn is you've got to engage them, and you've got to give them control. One of the things you see, see when you do, when you look at when digital transformation is when they happen and are successful, why are they successful? And most aren't. They're only about a third are. Two-thirds fail at a variety of levels, etc., but one of the things that you see as a success factor is they push the driving of the project as low as possible. They put the people on the front lines in charge. Now, they have a broad direction. We're going to go left versus right, but nonetheless, the format that it's going to take, that's your call and you put them in charge. So you take them out of victims' end of being the drivers, and that has an amazing impact on what they will do. So that's sort of one part. The other part is you say, listen, the change that we have is a never-ending incremental process. We're going to take a step and assess, take a step and assess, take a step and assess. We're going to iterate our way incrementally. We've got a big step, tiny little baby steps. So that eases the burden of familiarity because I'm not really going to be scared to death if there's such a big leap, we're going to take it, and I'm in control of the assessment and what we do next, etc. So the other is that when you introduce the change, you do so over periods of time. The one thing that, the digital transformation takes years, decades, it's not like you do it in two years, and you're done, you're a brand new spanking organization, looks really different than you were before. So give them control and move it incrementally in steps that sort of help them move along with that stuff, and then you get rid of barriers to degree to give them time, to give them money. You make sure the vendors know what they're doing. If things screw up, you help go in there and rescue the team to go along the way, or it strikes me, Steve, is the things that you and I learned doing implementation. That generation that succeeds us will learn all over again, and the generation that succeeds them will learn all over again. You know, I remember talking to a guy, Warren McFarland, who is a professor at the Harvard Business School, 50 years in IT, and I said, Warren, I know the technology's changed in 50 years, but what hasn't? He said two things. Timing still matters. You can be too early or too late to the market. And the second organizations are hard to change. It's like raising kids, the things you learn, raising and being a father your father learned, and your kids as fathers will learn all over again. So the other thing we learn is that every generation is going to go through the same relearning of this sort of highly experiential process.

Steve Lieber:
Yeah, yeah. We hope that there's something we passed on that you don't have to go through because I went through it for you, but there are limits to how far they talked about.

John Glaser:
You know, raising a kid. Sure, you'll do book learning, you'll talk to some colleagues, but you're still going to go through it, you know, in your own way.

Steve Lieber:
Yeah. So in several of your comments, you've talked about iteration as well as people walking into healthcare and finding out exactly how far along healthcare is compared to other places. And healthcare does regularly get bashed for being behind the curve, slow to adopt new technology, status quo driven, and that sort of thing. Is this fair and sort of give me a further elaboration on some points you've made in terms of where healthcare is and why we may have to do things a particular way and that sort? But we do, we get beat up on this point a lot.

John Glaser:
Yeah, and I think, by and large, it's unfair. I mean, if you think we get beat up, we don't spend enough. And they say, well, if you actually look at the spending, it's pretty middle of the pack here. It's not as high as banking or insurance, but it's not way down in the bottom 5%, that's for darn sure, etc. And so you got to be careful with the implication that healthcare is full of a bunch of laggards and Neanderthals who really don't want to move. That's not true at all. You've got some of the brightest, most driven people in the world running these things and wanting to do a good job here. I think a couple of things get in the way, one of which, the incentive system is still volume-based, by and large. So why would I spend money on this stuff or go through the implementation agony if there's no real upside? Come on, let's get real about this kind of stuff. You know, we're progressively moving to value-based care, and that may help. The second is if you look at the nature of the work, it is arguably the most complex industry that exists, the knowledge domain, massive in its size and growing exponentially. The nature of the work from very routine, run a chemistry test to, how do we do a really complex diagnosis. The political structures are complicated. It's one of the few, there are only three social economic goods in our industry today religion, education, and healthcare. We have to balance the societal mission with the economic mission, etc. So you say this, and golly, it's got a knowledge base, it's complex, its processes are complex, it's politically complex, it's got the wrong incentives. Hello, the IT will not be as far along as in other industries where those factors are lessened or more relaxed. All industries are complicated, I got it, but you could argue that we're trying to automate something which has no peers in terms of complexity. We've still got to get on with it because there's a lot we can do, etc., but we shouldn't bash ourselves because we're not moving that fast because it's not possible to move that fast, not in a thoughtful way and an effective way.

Steve Lieber:
Well, and I think there are a lot of things we can point to, of successes and advances in terms of the technology and the impact on outcomes and such that really do indicate that this is not, as you said, a laggard sector.

John Glaser:
Yeah. I mean, you look at the sort of extraordinary adoption of telehealth in the pandemic. Holy smokes. In a very short period of time overnight that fundamentally went up, etc. And you say that that did some real good. It was probably a little too fast and a little rough around the edges in some cases, but still, that did some real good.

Steve Lieber:
But we add to it, as like, you had no choice. You couldn't let anybody in the place, so you had to reach out.

John Glaser:
Doctors were coming in, opinions were coming in. You had to do something.

Steve Lieber:
Yeah, yeah. As we look over the past 15, 20 years and really it's continuing today, we've seen multiple occasions of non-healthcare companies coming into healthcare. And in the past, a lot of them made it for a year or two, and then they disappear, and then 2 or 3 or 5 or 6 years later they came back and that, that sort of thing. We're seeing it again, and it may be in some slightly different configurations in terms of more partnerships between big non-healthcare tech and provider organizations. What are you seeing in terms of non-healthcare tech coming into the healthcare sector? What's the outlook there?

John Glaser:
Well, I think Steve, we will continue to have it. Perhaps the rest of time, organizations that say, Jesus, a gazillion-dollar industry is all messed up. They really could use our help. We did a great over in this other industry. We'll just sort of port it in and they hit the like the old and the Greek mythology, the sirens who lead you on to the rocks. And you will always have that kind of aspect. I do think, and actually, I'm working on this article now, which basically says if you look at, quote, industries that have been, quote, disrupted, who disrupted them and to what degree did they really get disrupted? And you might think, and it turns out that the incumbents in the industry are largely the disruptors. It's the incumbents who drive the disruption and they affect the incumbents emerge stronger than they were before. You go through banking. Bank of America is still huge. JPMorgan is still a huge. Morgan Stanley is still huge. You go into insurance company Cigna still huge, all these etc. So what you don't really see, if the occasion you do like a taxi cab business where someone comes in and the incumbents disappear or get clobbered and all this kind of stuff here, etc. So I think one of the things that sort of we, the broader ecosystem in healthcare have to appreciate is the incumbents, the providers actually have a lot of strengths here, and if they're smart about it, they'll lead the disruption and they're beginning to do that. You see that in the patient experience or virtual care, etc. So where we'll work effectively is not when you have incumbent disruptor battling each other, as we say, we're going to work together to make this happen. I appreciate health system, you will be the driver because you can scale and you understand all this complexity that I really don't. But I'm here to help apply my technology and my resources, etc., to make that happen. So what I do think we're seeing, Steve, is a generation of both big Googles and the Microsofts and the Amazons startups coming through that, if they're smart, are humbler about what they know and don't know, and also realize that the disruption is through their customers, not them, largely, they'll help with that. They can bring all kinds of stuff that will go through that, that will work. And I see that sort of humility or appreciation more so now than we saw over the decades before.

Steve Lieber:
Yeah. As I listen to you, I'm struck by you continuing to be a student of healthcare. I mean, in your references, in terms of your continued reading as well as your teaching and that sort of thing. So let's talk about where things are going. And you've got an insight, One, you've got significant history, but your current, you're looking ahead and that sort of thing. Everybody's talking about artificial intelligence, and you can't have a conversation in healthcare without talking about it. And we all know the Gartner hype cycle and where we are on that cycle is up for some discussion, but I think we're in the hype area.

John Glaser:
Sure.

Steve Lieber:
What you read in terms of where this is going, its value, its contribution, its impact.

John Glaser:
Yeah, I think it's interesting, Steve, is, if you go back over the use of computers in the business community writ large, go back to the 60s, I think you see about every ten years a major technology innovation occurs that changes the world. The mainframe in the 60s, the minis in the 70s, the networked personal computers in the 80s, the 90s' was the web. You know, Google was founded in 1998. The 2000s was the mobile device. The iPhone debuted in 2007. I mean you could argue 2100 was kind of the internet of things, and here we're in this era of AI. So it's one, it's a big deal. And it's like its predecessors, the world will be different because of this thing. You know, you and I know how big, how different the world is because of the web. And you think about what that meant, and so there you go, it's big. And you're right, we all know there's the hype cycle and we got a lot of unwarranted optimism. And we've got some pessimism too. Hallucinations will kill people, this kind of stuff here. It's got to go on here. I do think, and when you look at it, it takes a very long period of time for mature use to really be understood of a technology. It takes decades, frankly, and it's still evolving. So when you look at the web and we're still learning about using of the internet for screwing up the political process, you can still see we're learning a lot in the last couple of years about how that's gone on, etc. So I think we will be learning for quite some time about AI, what to do. My general advice to health systems, and we do this through the Scottsdale Institute, etc., is you got to go through a year process of learning, try things, talk to your colleagues, go to conferences, read, whatever it is, or talk to consultants. Invite Google, Microsoft, all those people in to give you an overview of what they're up to, but learn and share that learning and begin to cut your teeth on it. Now, I think what we'll see, Steve, one, is we see areas where it's in place now. I mean chatbots. The Google lady who gets you map makes sure you don't get lost. You know it's all over the place already and pretty mature use. And you can see some examples like digital therapeutics for people dealing with postpartum depression. Wow, that's just really cool. You know how slick that stuff is? I think most of that use will be there and that kind of consumer-oriented stuff, but also in these sort of administrative areas of healthcare. And so this is completing the note for the doctor, this is looking at utilization management or prior authorization, etc. And largely because the ROI can be clearer about what's really I'm going to get here. If it makes a mistake, it's less consequential than hurting somebody along the way, and so that's where we'll cut it. And I think this notion of robot doc is a little farfetched, etc., but so that may be a little further out that we have to go to make all this stuff happen. So anyway, I think we'll creep, but we'll start with the administrative side, plus the stuff that's already ingrained, and in what we.

Steve Lieber:
Yeah, Judy Faulkner just last month at, announced that Epic's focus with artificial intelligence was going to be on in-basket notes, coding reimbursement, this or so administrative functions, and that sort of thing. And so it seems like that is the direction at least major players like that.

John Glaser:
Yeah, and I think, Steve, a couple of things. One is we have to be thoughtful enough to realize there's different classes of AI. There's the generative stuff, which summarizes a note. That's different from the stuff that says predict, that says, by the way, John Glaser is going to be a real estate heading south, frankly, on his care. We look a little wobbly here, which is different from what I call classification, which basically says AI, this is a tumor of the following type, you know, or pattern. So anyway, all three are in play, although we're all excited about generative at this point. The other thing is striking to me too, is on the one hand, Steve, we say it's going to transform healthcare. Oh, for God's sakes, I hate that word. We're going to disrupt the hell out of it. And I say, well, over time, but if you look at it's going to summarize the in-basket note, that's transformational. Now, that's a good thing to do, don't get me wrong here, but the point is we're taking really modest steps initially. That's fine. That's where you start, you know, and transformation happens over time. It's not this big step function where all of a sudden you go from being 6 feet tall to 12 feet tall. It's just not what happens in these kinds of things. So in a way, they look pretty modest, but they're the start. That's how you, that's how this stuff works.

Steve Lieber:
And you build on that, yeah. You sat in the CIO chair, you've also sat in the CEO of a company chair at major platform organizations like Siemens and Cerner. As we look at technologies as they've come in, there are usually a whole lot of players, and then there are big players in the same space. We'll use data analytics as an area, and as I just mentioned, Epic has identified what they're going to do in terms of building into the platform AI. Is that the likely trajectory that there are going to be point solutions as well as platform solutions? And again, looking at it from both perspectives, as you've been, where would you advise CIOs to be looking in terms of as you bring technology in, make sure it goes into the platform? Yeah, you're going to need some point solutions. It'll be a blend. What's your your take on that?

John Glaser:
I think what is particularly wise is to be at either end of the spectrum. You might say boy vendor X doesn't have it, I ain't interested. I'm true blue, you know that. Come on, that's a little, I mean, I appreciate the purity, but that's a little too much. The other is hey man it's FHIR-based, we can stitch all kinds of stuff together. Well, let's get real about how that really does work or fits into the workflow etc. One of it's striking to me, and particularly if you look at the growth of health systems, they're just getting larger, more sophisticated, etc. Which, that means is, they now have the IT talent that actually can afford and understands how to deal with different technologies. They may be true to their vendor, but they're not so true if they're not willing to try different things. So my general view of an idea is it's fine and expected that you will go out and work with companies that aren't as large as Epic or Oracle, Cerner or Meditech, etc., that have really cool ideas. And you want to do that because you want to learn and you want for all. This is really a breakthrough technology of some form. If they're going to get acquired and part of a larger monolith. So I do think you ought to be don't go wild and bring everything in that you can, but it's certainly prudent and smart to go out and to work with small, medium-sized companies that really have cool and innovative ideas. Not all the smart people live in Madison, Wisconsin, or Kansas City. I mean, there are some smart people, they don't all live there, and so you got to be, you tap into this sort of rich set of talent that exists across the board.

Steve Lieber:
Excellent. So, John, to wrap up, our listeners are CIOs, CMIOs, CNIOs, Chief Digital Officers, and that whole crowd. So what's your takeaway here? What's the one thing that you'd want to share with that group that you think might be something that they can take away?

John Glaser:
Well, I think first of all, it's just a really exciting time. I'm always, wish I had another, who knows how long they'll live or you will live to see. But golly, this much more interesting than it was 30 years ago, that's for darn sure, etc. I think the basic and it sounds kind of almost slogan-like here is, there's no question that technology can really improve the delivery of care, the financier care, the accessibility of care. So we all understand and appreciate how potent this stuff is, and it's getting more potent all the time here, etc. So you're in a remarkable position to help your organization achieve its mission, its goals, its that are delivering care. You really are. That being said, you've got to remember a couple of things. One is the skill, the bar on skills. Having been with China for a long time, it used to be that if you were, got a letter grade A as a CIO ten years ago, because your communication skill, your team building skills, that's a letter B today. The bar just keeps getting raised, not just for you, but for the C-suite writ large. So you just keep working on your skills and you know, this, that, and the other because the bar gets raised and it needs to, etc. The other thing to remember is a digital the adoption of the technology is a team sport. It's a sport that you do in conjunction with chief medical officer, chief nursing officer, CFO, etc, and the frontline, back to the earlier comment that we do here. So you've got to be, just remember it's not yes, it's you, I got it, but it's really you, the member of a team, and who knows how to pull together a team and get the team to work effectively, not only your team, but laterally across the organization. That kind of team here, so unappreciated, the sort of remarkable opportunity you have to shape healthcare. Do keep working on your skills, and do remember that it is a team sport. And we do that, and over the course of time, we'll make all kinds of progress.

Steve Lieber:
Outstanding. John, as always, it is an absolute treat to be able to spend time with you, and I certainly do appreciate you being with us today.

John Glaser:
Well, thanks. It's a pleasure to spend time with you and great questions, and I hope people find the answers interesting. I'll look forward to seeing you next time we get together.

Steve Lieber:
Excellent. Thank you. And to our listeners, thank you for joining us. I hope this series does help you make healthcare smarter and move at the speed of tech. Be well.

Intro/Outro:
Thanks for listening to Smart from the Start. For best practices in AI and ambient intelligence, and ways your organization can help lead the era of smart hospitals, visit us at SmartHospital.ai, and for information on the leading Smart Care Facility platform, visit Care.ai.

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