Episode 18 : The Shiny Object Syndrome:

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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 health care. Join Steve Lieber, former CEO of HIMS, 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's my pleasure to bring to you a series of conversations with some of the sharpest minds in health information technology. On these broadcasts, we discussed the smart directions healthcare companies and providers are pursuing to create smart care facilities and teams. Today, I'm joined by Doctor Rob Bart. Doctor Bart received his medical degree from the University of Hawaii, followed by training at Duke in pediatrics and critical care medicine. Doctor Bart formally started working in Health IT in 2000, while on the faculty at USC and Children's Hospital Los Angeles. In 2007, Doctor Bart moved on to a role as CMO at Cerner Corporation. In 2012, he was the first CMIO for the Los Angeles County Department of Health Services, and in the summer of 2017, Doctor Bart moved to Pittsburgh to become the CMIO of UPMC as CMIO at UPMC, Doctor Bart has taken on clinical leadership of all clinical applications. Welcome to the podcast, Rob.

Dr. Rob Bart:
Ah, thanks for having me, Steve. It's nice to be here, and I'm looking forward to a good conversation. As you mentioned, I've been here at UPMC just over six years. It's been incredible learning operational and work experience.

Steve Lieber:
Well, I expect that we'll cover something of a trajectory that you went through pre-pandemic, pandemic, and post-pandemic. And so being in one place during those three somewhat different time periods is going to give us some perspectives that I know that will explore. Where I want to start out is sort of the unique position that UPMC is in, that you folks are very focused on risk-based care in terms of what's going on, your background as pediatric critical care physician, and you've been a clinical informaticist for a long time. You're at the intersection of clinical practice and IT, and so there are several directions there, including your time at Cerner, that's going to give us some perspective. So given your lens in both, uh, health providers and solutions a little bit state of the union, let's say around digital health, let's start out with what are the bright spots that we're seeing right now around digital health.

Dr. Rob Bart:
I'll get to that in a moment, Steve. I think it captured a bit of my history. It'd be remiss to not state that. I do believe I am a better and more well-rounded CMIO because of my experience working at Cerner. I think one of the things of working at a publicly traded company for a number of years is it really forces you to learn how to bring value to your job and what you do at work on a daily basis. And that's something that I think I didn't get as exposed to when I was a more traditional academic physician. And as I moved it more and more into the realm of Healthcare IT and the exposure at Cerner, understanding that and then bringing that back again on the CMIO side, both at LA County and then here at UPMC, it really sort of drives home that necessity of bringing value. I think the other thing it helped me do is understand how to evaluate technologies, how to evaluate companies, how to talk to companies, and sometimes even negotiate with them about their solutions, and really sometimes teaching them how to think about their solution and what it might solve.

Dr. Rob Bart:
To your point now moving it towards to today, things have been especially coming out of the pandemic. As you mentioned, the amount of investment in healthcare IT has been pretty remarkable. And so there's a lot of opportunity out there for technology to be reviewed, thought about, potentially contracted with, and brought into a healthcare system. In fact, the amount that's out there is somewhat overwhelming. And certainly, you're well aware of the financial constraints that healthcare delivery systems are under as we've emerged from the pandemic. And that really means that your evaluation and your understanding of the problems that a solution can solve, as well as the potential return on investment that it has, has to be very clear in today's world, when I talk with our financial officers or our CFOs, they're very interested in technologies that will help us be more efficient or more effective, technologies that will allow us to engage with consumers and patients more effectively. But they want something that will return an ROI in that initial 12 months. They're not interested in two, three, five years down the road, which is...

Steve Lieber:
No more of that three year. Okay. You've got time to to ramp it up. And payback can start in three. They're looking for one, interesting.

Dr. Rob Bart:
That is quite stark. And you know to your comments about the pandemic pre-pandemic most times when we're talking about engaging with a new vendor, on a technology or platform. You were given two, three, 4, or 5 years to ramp up and show that ROI, and you could show the financial math on where you would break even and where you'd get that return. Now that window is really compressed. It's a combination of, I think, the financial circumstance and states that healthcare delivery systems across the US are in, as well as the expectations of how fast we could accomplish tasks and sort of turn on a dime that we learned through the pandemic itself. A lot of healthcare systems, including UPMC, ramped up telemedicine from essentially far less than 1% of visits to up to 1,820% of visits, ramped up a number of asynchronous digital technologies. We were able to do it quickly and effectively, and so we partly created that expectation with the people and operations, and finances. But also I think it was the consumer and patient who also generated that expectation that we were trying to meet. As far as specific technologies that UPMC has been looking at that we're interested in. Certainly you can't go anywhere without discussing ambient voice, and that's something we're very high on, very interested in, and also looking at ways to ease the digital interaction with patients. You know, one of the things that you and I think the audience is well aware of is that healthcare, like many industry verticals, has had staffing challenges coming out of the pandemic.

Dr. Rob Bart:
Some of the staffing challenges there, not just the RNs, but many of them are the operational support staff, like those that might be in a central phone center. And so the more of the interaction that we can move into a digitally mediated as opposed to a human mediated, it both simplifies the process, it allows the consumer to control it and interact in a more efficient manner, but it also decreases the human operational burden that the organization has to solve. So those are areas where we're extremely interested. An additional one would be those solutions that allow us to be more efficient or effective with what we do within our healthcare system. There's a number of solutions out there that work in trying to improve perioperative efficiency, though many of them have AI algorithms because the math is so complex, and how to improve block utilization in an OR or how can we push more patients through a limited capacity system? Similarly, in the ambulatory environment, we're looking at the same thing. How do we make our clinics more efficient? Is really adding to more examination rooms going to be more efficient for that clinic and allow better throughput? Or is the limitation the personnel that we have, and we have to figure out how to utilize our personnel better. And those, again, are somewhat complex math problems that really AI algorithms can help us resolve and improve the efficiency and effectiveness of UPMC's care delivery.

Steve Lieber:
I'm going to piece a couple of things together here, talking about the CFOs and their need for ROI analysis. And then as you've talked about some specific things here, you've talked about efficiency, you've talked about staffing and other multiple metrics. And so what I'm sensing is in looking at adoption of new technology or evaluating what you've done, you need to be looking at it on Multidimensions. Is that what I'm hearing in terms of that kind of analysis?

Dr. Rob Bart:
You're absolutely right, Steve. You have to do a multidimensional analysis. The other piece is you have to have clarity of thought of the problem you're trying to solve. As I think back when I was interviewing for this position, one of the questions that I think kept coming back is I kept talking about the problem that you're trying to solve, the people that perform the task, and what is the workflow in the process there. And I think the fact that I juxtapose and positions those ahead of the actual technology is a lot of what generated the interest in me ultimately being here at UPMC, and that's still a focus of how I think about its problem. People, process, platform, then performance is where I think about it. But a lot of times when someone brings a shiny object to me, and we've got a lot of wonderful, innovative clinicians here at UPMC and innovative folks in operations, and they pay attention to the technologies around them, whether it's colleagues or other healthcare systems or at conferences. And they bring back good ideas, but when you ask them, what are you trying to solve with this technology? Until we get to clarity of that focus, we don't start marching down the road of looking at a shiny object without having that discrete understanding.

Steve Lieber:
So take us through a little bit of the thought process, or even maybe the decision making process of how do you about which one there are, as you've indicated, a lot of shiny objects here. And so where is it that you go or are you looking at? And, you know, it's probably all the above patient experience, clinical experience, clinical outcomes, business efficiency, how do you decide?

Dr. Rob Bart:
It is a challenge. But to that multidimensional analysis, it's almost sort of a balanced scorecard approach of whether you're achieving in the patient experience, what do you have achieving in operational efficiency relative to the investments of the finances, and the outcomes you expect. But there are other factors related to the technology itself that we look at. One example, without naming the company, we were a relatively early adopter in radiology imaging using FDA-approved imaging algorithm for the identification of strokes. And it's something, as you know, the identification of a stroke and how the brain functions or how the brain doesn't function when it's not getting enough oxygen, minutes and seconds matter. It's one of those areas where the sooner the better for the patient and the outcome. And there were a few companies in that space. One of the things that drove us towards the entity that we ended up choosing was they weren't just looking at being an endpoint solution, they were trying to look at how that algorithm could be an entree into an imaging platform that could support a number of AI algorithms, and to me, someone who has to work with the hard-working IT people who have to integrate thing solutions, a bunch of endpoint solutions is a lot of back end work. But if I have an algorithm that's now going to be driven off of an extensible platform and allow other algorithms to be on there in the imaging space, that simplifies my job.

Dr. Rob Bart:
It simplifies the amount of maintenance and work effort that we have to do, and ultimately it becomes something that we want to integrate into our ecosystem at a platform level. So one of the things that we look at is when you're really, really at the leading edge of being an early adopter, you are frequently forced into single endpoint solutions. If you can do a little bit of homework in advance and hopefully figure out the philosophy of how that company you're working with thinks they might be the one. Sometimes you're going to guess wrong. They're not going to be the one that survives or the one that makes the right platform. But sometimes, waiting a little bit and seeing how those companies develop over the first few months, a year, we'll give you an inkling as to which one's going to be the better survivor, which one is going to actually be more thoughtful about developing a platform or an ecosystem approach? And all of those things translate into the opportunity to have a better investment, both operationally and financially, and a better operational financial investment in the long term means that there might be more money available in the future for other healthcare short-term IT decisions.

Steve Lieber:
And these conversations, as well as some other work I'm doing, this focus towards platforms versus single point solutions comes up regularly, as sometimes people sort of think about it, oh, you're taking the long view. Well, yes, but start it from the beginning. You don't need a bunch of short-term views of point solutions when, as you just said, take a little more time, look at what's being developed, what's the opportunity. Because you know this, our listeners do, having to install and deal with a bunch of point solutions is so much more inefficient. And in the long terme isn't where you want to be.

Dr. Rob Bart:
Yeah, that's absolutely correct. I mean, I remember prior to the pandemic, VR Solutions were sort of becoming really popular. And somehow through the course of the pandemic, that all sort of faded to the background. But it was a bit challenging because every surgical subspecialty was bringing to me a really what seemed like a well-thought-out VR solution, but it was specific to their surgical specialty, and I had to tell many of our department chairs in those specialties, UPMC, we can't afford to contract as well as implement ten different solutions. We need to see how this market sort coalesces and figure out if we can figure out who might become a market leader in that space. So you hit applies not just in today's technology, but it's something that we've applied as we've thought about technology investments over the past six, seven years.

Steve Lieber:
UPMC has been known for some number of years for its innovation center, the home develop technologies that obviously are utilized within the system as well as commercialized. How do you relate to that work, and how well does that fit into practice?

Dr. Rob Bart:
So I think you're referring to UPMC Enterprises, which is one of our business units here. I work very closely with them. There are two Jeanne Cunicelli and Brent Burns, who oversee both the life science and the digital portion of UPMC enterprises, respectively, and are arguably somewhere between brilliant and geniuses, and I've learned a lot from both of them. We've worked on really improving that process, but the key ingredient there is they're working to identify technologies and maybe early-phase companies that are trying to solve problems that UPMC has. So when I got here just over six and a half years ago, it was a good process, but it wasn't as smooth as it is today. And occasionally, like the old adage said, they would bring me a hammer for a nail I didn't have. And I'd say, that's great technology, but who's going to sponsor it? What problem are we going to solve? We've collaborated a lot more over these years, and they spend a lot more time with us on the operations side, so they can understand the challenges that we have in the care delivery process, or they can understand the challenges we have in pharmacy or on the health plan side, with sort of an inherent belief that if UPMC has this challenge or this problem to solve, other healthcare systems have the same challenge or problem to solve, then that's when you get a really good partnership between the operational clinical side and then enterprises investment development arm, particularly when we're working with early-stage companies where the company may have a very good idea, a very good solution, but it's not completely matured. And they need sort of the interaction and the intellectual property of working with our clinicians and operational folks to really mature that solution set.

Steve Lieber:
Excellent. So in looking at some more recent developments, and you've touched on AI in terms of how you're already using artificial intelligence, we've talked about ambient technologies and the platforms. And I see sort of a coming together of several things where we've spent years digitizing data. Now we're starting to figure out how to get in there and use it and such. So what's your view in terms of artificial intelligence as a tool for use across the enterprise here? Where do you see it, the stage now some thoughts about where it's headed.

Dr. Rob Bart:
I think it's pretty clear that a couple things. One is artificial intelligence is not going to replace clinicians, okay? But the clinician who leverages artificial intelligence is going to be much better positioned than the clinician who does not leverage artificial intelligence. I think that's a very true statement. And then when you explode that to a larger healthcare system, it becomes incumbent upon us to make sure that we're exposing the right artificial intelligence opportunities to our clinicians. I mentioned in imaging that we've brought in some artificial intelligence. There are other clinical use cases that we've been looking at and evaluating and testing. And for the most part, on the clinical ones, we're following the guidance of what the FDA's approving and how they're moving. When you move away from just the straight clinical guidance, I think there's sort of, uh, at least two buckets. One, so UPMC is headquartered out of Pittsburgh, which happens to have two universities, one of which is where artificial intelligence was invented or found, depending on how you believe it at Carnegie Mellon University. And it puts us in a good position because of the people that graduate from these programs. And many of them like living in Pittsburgh. So in one area, operationally, we have a group of people that have been very astute at using and developing artificial intelligence algorithms to look at readmission risk of our patient population, predicting length of hospitalization, other types of operational metrics that are related to the clinical experience and environment.

Dr. Rob Bart:
But they're not directly related to the clinical diagnostic area. It's about the big picture of how you manage and operationalize your organization. And so if you can have good predictive analytics on when patients potentially might be able to be discharged and what the risk of readmission is, you can start planning the throughput for your organization much more effectively, and so that's been very helpful. And then the other area I think, and you mentioned ambient voice in the artificial intelligence space is I think we're still on the I think the front edge of what it potentially can provide in healthcare. One of the things that got me into healthcare IT early on was electronic health records in the early to mid-90s, and I remember talking one of the first EHR implementations I did was at Children's Hospital Los Angeles. And I remember talking with one of the pediatric oncologist, and shortly after that implementation, he was so happy that he could go home, see his kids, see his wife. But then he spent two hours being able to document at home. So the fact that he could move it to home instead of staying at the hospital or the clinic was very important.

Dr. Rob Bart:
Five years later, though, when I talked to the same physician, he was still doing that. And that elation of being able to do at home now became this burden of every night from 8 to 10, I've got two hours of documentation to do. And unfortunately, I think that the early electronic health records with all of the different documentation tools or traditional voice-to-text or templated types of things that we created, it didn't matter which vendor they all utilized about the same playbook, they didn't help the clinicians become more efficient. They didn't help them become more effective. And in fact, on top of that, we may have had created higher expectations of the amount of documentation. So we may have also added to that burden inadvertently from a billing and clinical perspective. Come to 2023-2022, Ambient Voice is actually the first opportunity to change that circumstance. We've worked with two of the leading companies in this space. We've had very productive, very good. What I would say is protracted development cases with them, allowing clinicians exposure to them and working with them to feedback. It's one of the few times where the feedback is universally very good, but it's only very good for those that adopt it, and our experience is not too different from my colleagues at other organizations where it seems like about 60% or so of physicians and APPs seem to adopt ambient technology, there's a 30 to 40% that either the templating they do is so highly structured that they're extremely efficient, or there's something about the ambient technology itself.

Dr. Rob Bart:
Maybe it's the recording and, you know, there's the we're trying to dig into why there's something about it that they're not that impressed or overjoyed with. But for those that adopt it, the types of things that they're able to do, whether it's leave the clinic on time, you know, if the last patient's out at 5:15, they're out the door at 6:00 with all their notes done type of thing. On occasions, there are abilities to add maybe more patients to the schedule, which from a productivity piece that's very good, and also from a patient experience, being able to get more patients in the door sooner, that's also very good. So the early read that we have on these ambient technology, particularly in the documentation space for Physicians and APPs, is extremely good. It's not inexpensive. It is definitely something you have to decide as an organization that you want to invest in, both for your clinicians and potentially for the improvement of the care for your patients.

Steve Lieber:
So a key takeaway, multiple wins there, but one in particular is its value to the clinician is key to their acceptance and adoption and use. And sort of that story back from the early adoption of EHRs and the challenges that we put on clinicians fed a lot of clinical resistance to use and such because one, we cause people to spend more time at the keyboard instead of with the patient. I mean, there are all kinds of things that we did there. So I'm sort of taking from your remarks, maybe we're getting better with the technology and recognizing you need to early on, like your CFO, you got to deliver value in that first year.

Dr. Rob Bart:
Yep.

Steve Lieber:
All right. Let's wrap up with a final question here. Our listeners are people like you, CMIO's, CIOs, CNIOs, digital officers. What we always like to close with is single most important practical piece of advice, something that you have learned, you've come to recognize that you would share with our listeners.

Dr. Rob Bart:
I sort of shared the rubric that I go through earlier, which is identifying the problem. Who are the people involved in that workflow? What is the process or the workflow? Then you identify the right platform and then you measure the performance. So those five P's I think so many times when something sounded so good that we didn't pause to make sure we identified the problem we're trying to solve. You ended up with a project that goes a little bit sideways, and you have to go back to the drawing board and make sure that you really are identifying the problem, and that's the one you're solving. I think it's very, very important and it's basic and fundamental, but it really has allowed me to be a better steward, especially as money for technology gets tighter. You really allows us to have better conversations, to be better stewards of what we're doing for on the behalf of our clinicians as well as our patients.

Steve Lieber:
I'm glad you went back to those five P's because I wrote them down when you said it the first time, because that was a big takeaway for me as well. I think that is an outstanding way to put this all together and think about a continuum that you must go through as you deal with these issues. Rob, it has been a great conversation. I really do appreciate the time that you've given us today.

Dr. Rob Bart:
Well, thank you so much, Steve. I've enjoyed being here and I hope that your audience enjoys the conversation we had today.

Steve Lieber:
I know they will. There are just so many key points in your conversation today. So to our listeners, thank you for joining us. I hope this series helps 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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