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 Thanks for joining us on this week in Health IT Influence. My name is Bill Russell, former Healthcare CIO for 16 Hospital system and creator of this week in Health it a channel dedicated to keeping Health IT staff current and engaged. Today we are joined by Andrew Rosenberg, CIO, for Michigan Medicine.

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Common question I get is how do we determine who comes on this week in health it, to be honest, it started organically, it was just me inviting my peer network and after each show I'd ask them, is there anyone else I should talk to? And then the group, obviously the network group, larger and larger, and it helped us to expand our community.

Of thought leaders and practitioners who could just share their, their wisdom and, and expertise with the community. But another way is that we receive emails from you saying, Hey, cover this topic. Have this person on the show. And we really appreciate those submissions as well. You can go ahead and shoot an email to hello at this week, health it.com, and we'll go to the, to the entire team.

We'll take a look at it, reach out to these people and, uh, see if there's a good fit to bring their knowledge and wisdom to the community as well. Just a quick note before we get to our show. We launched a new podcast today in Health it. We look at one story every weekday morning, and we break it down from a health IT perspective.

You can subscribe wherever you listen to podcasts at Apple, Google, Spotify, Stitcher, overcast, you name it, we're out there. You can also go to today in health it.com. And now onto today's show. Today we are joined by Andrew Rosenberg, CIO, for Michigan Medicine. Andrew, welcome back to the show. Great. Thanks Bill.

Well, I'm looking forward to the conversation as is usually the case. You and I have a 10 minute conversation that I wish I recorded the whole thing, but we'll get into those things. Uh, I saw that you moderated a session at, at the chime forum. How, how is that to be on the moderator side of the equation?

Well, you know, as you and I were just talking about, on one hand it's extremely efficient and great of course, during, as we recover out of Covid, to still be able to get together, to still hear great ideas, to be connected on that hand moderating or participating is fine, but you know, my style at least, and one reason why I love meetings like Chime or Scottsdale Institute or Health Management Academy or whatever is.

Especially when you're a moderator, you really have the ability to draw in people in the audience. We're a big community, but we actually know each other a lot. And one of the parts that I am missing tremendously are the meetings in person. I get the efficiency of doing it remotely, and I know we're gonna still be doing some of that, but.

It offers such a deeper experience. You can look at people's expressions. You can follow up on something that you get a sense that people wanna hear more about. You can try to move away from something that we just keep repeating over and over and over and it doesn't add value, and you can add a little bit of spite.

Uh, I've done that before at some of our meetings, and I don't do it to be a, a jerk. It's more I just try to emphasize a theme. In this case, for example, I had talked to John Halamka before the meeting. We were emailing with all the participants. 'cause I wanted to be able to connect and not make and make sure that people were not just repeating with each other.

And I love the debate about buy or build your own, especially in the areas of health it that are new. Yeah. Do we go after vendor products or do we have to develop our own? And there's a reason for both. It just so happens that Mayo Clinic and the Mayo Platform is extremely well known for building their own, and yet I'm finding often when you try to build your own, you run into all sorts of conflicts of the resources to do it or the priorities or things like that.

So it's not a right or wrong answer, but what it is, it's a topic that I know you can draw other people in because we all have these issues and as a moderator. It's essentially impossible via zoom or teams to spark that kind of fun and educational debate. So I'm looking forward to doing it in person.

Yeah, I had my first meeting in a long time yesterday, a, uh, CEO for a startup startup, a 20 year old startup in healthcare. It happens to be in our area, and so we decided to get together for lunch. It was the first time in a long time that I sat across from somebody. I forgot how dynamic it can be. This sounds silly to even say, but I forgot how dynamic the conversation could be.

How one thought leads to another thought leads to a discussion and how he was sort of trial ballooning his thoughts and ideas on me. And part of that is seeing, you know, is this resonating with this person? Are they, you know, what's their facial expression are?

Over the last couple of months and, and he was responding to it and it, there's just something about that that helps us to fine tune our thinking, fine tune our presentation of the, uh, facts and of the argument so that we can be better the next time we're going to have that conversation. And that was just a one-on-one lunch.

I don't know about, are you having pretty often lunch meetings with people sitting across from them or are things still pretty much remote at this point? No, I, I, I would say Michigan unfortunately had this bizarre and still not quite explainable surge in the US of cases more than any other state. And so socially within the state at least, I think we were more restrictive than we might ordinarily have been.

I'm finding it personally a little bit challenging because most of my professional colleagues have been vaccinated now for several months, and the data I think, are pretty strong to support an extremely low risk of contracting covid, let alone really getting sick. I think the real issue, of course is not just you get covid, but you get really sick by it.

So I've been feeling much less restricted and I do go out and I do have meetings or lunches, but I would say overall we haven't been there. But you know, your earlier point I think's relevant about these, uh, where we're gonna be with remote work. I know that's a topic we're all talking about, so why don't we just dive into that very briefly.

Sure. I think this kind of format that you and I are doing are actually still really good for the one-on-one type meetings. And I do think one of the areas that we're gonna see persistence of remote work that will be different than before is that we'll use video meetings. To do what you and I are doing right now because I can't actually see your expression.

I can see it mimics the in-person experience pretty well. Add a third and a fourth and a fifth person, and that benefit diminishes, I think very significantly. But the other piece of course, is especially with groups of people, it's not just what we're talking about right now. It's the, oh, hey, I got a quick item just afterward, and they grabbing someone in the hall or just running over to their

Office that you can do quickly versus having to, you know, drive to someone's office. So I do think the one-on-one, and especially where we couldn't do it before, much different than a phone that's gonna persist where I, where and, and I might be different than my peers. I, I feel like I'm in the minority on this one when it comes to our, we're calling it flexible first.

Most of our IT colleagues. When we've surveyed and we've done some really good surveys, which I would say is one of the most important things to do, survey the groups, find out where people are now and where they think they're gonna be wanting to be in six or nine months in terms of working remotely, whatever.

I think in two years, more than not, people are gonna be back together. Remote. And I think the advantages and the desires that people are expressing now to be able to work remotely, not have to be in the office, things like that. I suspect they're gonna be two drivers for why they're gonna be back in the office more than not.

Uh, in two years from now, by the way, I have, I have thoughts.

From, uh, JP Morgan. He, he was very vocal on this in his annual letter to shareholders, but I'm curious, what, what, what are the two reasons that we're going to end up back, uh, together, do you think? Okay. The, the two are as follows. The first is the biology of humans being social animals and the biologic drive to group and be together more than not.

There's a variability. I get it. I think the advantages of the flexibility that remote work offers, which are very real will over time just diminish a bit and the biology of people wanting to congregate will we'll change that equilibrium. So that's first the human need to stay connected in person. By the way, my my point about the meetings.

Is as much of that. I also think that we do need to, and we want and we seek to disconnect from the routine in order to have a more creative, more flexible kind of thinking that we seek at meetings, a change of pace, whatever those things are. But I think those are partly driven by human psychology and human biology.

The other one, which I think is more interesting, will be the, I guess I'll call it the peer pressure maybe. I think it's gonna be a little bit difficult to fight the pressure that one will feel all of us when a group of peers or your boss is meeting in person with people and you are not there. Right. I think that'll also be variable.

I think different people will react to that very differently. I know that when I think about what I'm going to be doing as the CIO, I need to be really clear to people, to be very sincere and the way I wanna do it, to support our flexible, first, the way I wanna do it is to have our meetings set up as for our case, zoom or team meetings.

Now if the person happens to be in the office. When I'm in the office and we realize, you know, we're doing this as teams and we're literally three seconds away from each other, I imagine we'll just shut off our video and we'll go to one of the other's office. That's what I suspect will happen. But instead of saying, Hey, I'm gonna be in the office on Monday, but we can do teams, I think the way I'm going to do is say, Nope, it's gonna set up as a remote meeting.

So that I can at least support the flexible first uh, style. I don't want people to feel Wow, Andrew in the office. Therefore, I have to be there because I don't wanna do the same thing for my boss. Right? We have a couple leadership meetings that have been very difficult for us to come to because some of us who are not in that exact building, we have to drive, we have to park, we have to find it, and 45 minutes later, then we have to reverse.

I. A couple of our leadership meetings will stay virtual meetings because we know so many of the leadership at a large place like Michigan Medicine. Not everyone is all on the same floor to get there, but two years from now, I'll be curious how that works out for those people who are physically around and can be with the boss and those who are logging in remotely, and what will be the social dynamic.

So. My bottom line is in two years from now, I think we still will be taking advantage of flexible remote work, especially with hiring people who will be in different parts of the country that I do think there'll be more of that than we've had before. But I think more often than not, people are gonna feel some pressure to be congregating in person.

Yeah. I.

He just went through his workforce and he said, look, these people have to be on site, these people. And, and when he got done, he is like, okay, so 60% of our workforce at JP Morgan have to be on site, period. I mean, they just, there, there's no way to be a bank teller remotely at this point. And we, you know, we went away from bank tellers and everything was gonna be done online, that now we went back to bank tellers because we wanna be more personable and service oriented and those kind things.

Well, the same thing true in health. It. Or just healthcare in general. A, a significant portion of the population has to be on site, and so there is that peer pressure, that draw of not being there. He also talked about mentorship. It's hard to do mentorship remotely. So bringing on new employees, training them in some of the skills that they're going to be required to have is, is hard to, hard, if not impossible to do via Zoom.

And so there's there, there's a lot of different aspects to it, but I like how you're approaching it in that there, you know, the satisfaction with it.

The reason is, is obvious. It's the flexibility. It is, uh, less commute. It's all those things that we know are an advantage. And I think people will like it today, but I think they're going to, everybody's gonna need to find their balance with it in what really works. Right? And, and I think what's really going to persist though is, and that's why we're calling it the flexibility, you know, it's not remote.

It's flexible and snow days. There's no reason why someone should drive in if they physically don't have to be sorry, kids going to school from now on. But I think when someone is needing to do something else, but they have really what is important, it gives them the flexibility to remote in for that one thing that's important.

And I think that'll help with work life balance perhaps more than anything else we've ever done. On the other hand, of course it does. I think we've all experienced some sense of we're actually working harder in some ways. You know, meeting after meeting, after meeting, after meeting. Never getting up.

Never moving around. So the, I think for us, one lesson is, and I've already alluded to this, we have to make some efforts. To really sincerely demonstrate, number one, I think it's perfectly fine if you wanna meet with me like this. And number two, I'll do everything I can to try to promote it and certainly decrease any sense of obligation to not do it.

Uh, at the same time, I don't want to somehow artificially keep people from joining and getting together because not only do I miss it, I do think that there are a lot of opportunities. You mentioned a. Uh, uh, mentoring, I would add serendipity and creativity. You know, often it's that, Hey, we're just gonna go get a cup of coffee.

It just changes the dynamic to think a little bit more expansively, especially around complex and difficult problems that don't lend themselves to just being solved easily. Yeah, I believe there's something about how you can bring people together that still lets them have that flexibility. But I also don't wanna artificially create more remote everything and not allow people to come together.

So I, I think we'll find the balance, but I do think it's gonna take a few years. You know, I, as you know, I have a bunch of different questions. We can go in, in a lot of directions here, but I wanna, I wanna start with, and I meant to start with this, we just tend to dive into it. What, what's top of mind at Michigan Medicine these days?

What is like front and center? For you guys. I think we talked about probably the number one thing that's both new and front and center, all things. How do we support flexible, hybrid, remote, whatever term you want to use for my peers and I, everything from what kind of scheduling system you'll be using to policies that are in place are being changed to.

What's your best guess of your workforce? Who will be working to. Recruiting, retaining, all of those things are front and center, not only in it, but really throughout the health system and the university. And so, you know, at least for us, being at the University of Michigan, all those things play pretty, pretty heavily.

But from that, a few things are also gaining some momentum. The one that I am most interested in dealing with, which is a massive. Project or series of projects, and it's almost difficult to put it into words, but I'll try, is something like this, creating the framework for moving workflows, infrastructure to cloud solutions to a variety of as a service software infrastructure platform.

And how to create that framework with also thinking about your application, we'll call it application modernization and how that relates to cybersecurity, to business continuity, and frankly, even some overall principles of how one will engage with cloud. I'll call it cloud for now. I think most of . Your, uh, viewers and listeners, we understand what we mean by the complexity of that term, the cloud.

So all those things are wrapped together, and for us, one of the instigators of this is we have to update or replace our secondary data center. And immediately as you start getting into that discussion, there are a lot of circular items that I've had to deal with. So I'm trying to figure out how to tackle all of that and not just move to the cloud.

Or what Epic hosted is gonna look like because we do have investments in data centers that still are financially high value for us, as opposed to perhaps others who've had, you know, least data centers where it just makes sense that you have to go to someone else's. So that's probably the among the biggest things that I have to deal with, and that's gonna be a, I don't know.

10 year project. The other one are some of the new areas of care. I'm extremely interested now, this is partly because I'm doing TeleCritical care with the va, but I've always been interested in this around remote patient monitoring, true hospital care at home, how to take the lessons of virtual care and really continue to shift that paradigm, not just care at home.

But how do we improve capacity in our tertiary hospitals, improve patient engagement and the experience in our clinics so that there's less wait time in part by shifting some of the work to areas where people really want it IE at their home. And I do think that that's an area, whether it's edge computing and IOT with five G capability over time, really allowing that to happen.

That's another area where I really see a number. Of themes only growing. Here's what I'd like to do. I'd like to start high and then move low. You gave me a lot of things to think about there. Let's start at the high level, which is are we at a point now where the technology is driving business strategy, or are we still at a point where we're saying, no, no, no.

Technology serves the business strategy and therefore the business strategy dictates the technology. Does that make sense? It does, and you know, my experience has been they, it's almost like a quantum state. No matter what angle you try to view it at, the other angle can be equally relevant at the same time.

I've been doing some reading about quantum these days and super positioned, so I might. Inadvertently or inappropriately add too much of that to this conversation. But I, I really think it's true. You know, I, I would say a classic teaching would be start with your business strategy and have the technology support the business strategy, whether it's clinical item or a academic item, or an education item and, and conceptually that makes a lot of sense.

But I've seen equally. Because we don't really define that business strategy or do it well, or the governance is such where you can't really quite define it crisply enough where then the technology actually helps to constrain or shape or direct, I mean, this is the classic example. Years ago when we were all doing EHR implementations, we would say, let's get our workflows right.

Aligned. Aligned and then build the EHR to support that. But often the EHR kind of helped constrain what was otherwise an ungovernable series of requests, ambulatory care and inpatient care, specialty and primary. They could never agree on a very precise strategic and tactical alignment. So you would say, I know you wanna do that bill and you wanna do that, you know, Sally, but

EHR just allows us to do it this one way. That's the way we're gonna do it. Now, if we did that all the time, that would break business. So I see them as being very interwoven and in some ways, one will get out ahead of the other, and you just want to try to keep them in reasonable balance, but not lead with one and let the other follow.

That's a really interesting and phenomenal answer. That's gonna stick with me. I'm gonna stay at a high level here for a second. You know the history of Fortune 500 companies like you used to last as a Fortune 500 company for like 60 years. Then it's down to, I think now it's down to like 25 or 30 years for the average Fortune 500 company.

But the reality is that a majority of the largest healthcare companies have been around at their level for over a hundred years. So we were built as an analog. Kind of of of business, right? Things were paper-based, things moved by word of mouth, things moved by papers, moving around on clipboards and those kind of things.

And now we have this technology. First of all, we've digitized the medical record. We've gotten to that point where I think we can safely say we've digitized the medical record. Now we have a ways to go still on cleaning up. The content of that and whatnot. But we've digitized the medical record now. We have all these other technologies out there.

We have artificial intelligence, machine learning. We have really some powerful data tools and data insight tools, and we have things like this. We have things like the ability to see a patient remotely. We have remote patient monitoring type of tools and that kind of things. And so when I, when I hear you say it, it's both.

Uh, it, it almost feels to me like we're at a point where we're, we're taking this analog, we're taking this historical process that we've had in healthcare, and there's really two approaches that people are taking. They're either just overlaying the technology on top of it and hoping that it sort of works out.

And, and that seems to be the predominant approach. It's like, we're gonna inject, right, uh, this here and inject this here. Do we have any appetite for rethinking it from a digital mindset, from a digital world and saying, Hey, is there a different way of approaching healthcare given this new set of tools that we have?

I think we've been constantly trying to do that. I think that the shift from inpatient care to ambulatory care, the shift of procedures, . From hospitals to dedicated surgical sites, the shift from big open procedures to more and more laparoscopic and catheter-based the the shift to trying to completely eliminate diseases.

Now with gene editing CRISPR and gene therapies and immunotherapies, the goal is constant. To try to shift from those things that we deem as inefficient to, uh, more patient centric, more humane, less expensive, whatever. This is the pursuit of healthcare. This is the basis of, of disruptors trying to come into the market.

So what what I'm finding is, you know, I, I sure hope I'm not proven wrong, but. I hope my CIO and IT colleagues would agree, I'm getting a little bit more comfortable now than I was before when I'm talking to really innovative and and energetic younger people who wanna disrupt healthcare. And I'm finding myself being one of those people starting to smile a little bit more calmly, like, yeah.

I know it sure sounds like you should just be able to go in there and with this technology or this new workflow or this methodology just disrupt things. Healthcare is really complicated, very heterogeneous. And one thing that you think of that might be healthcare is very different for someone else. So I, I am much less worried that our directions are being dictated by new technologies or somehow technologies are leading the way.

At the same time, I also think it will be through technology where the real big shifts in healthcare will occur. So there's this duality that I mentioned before that I see so frequently wrapped together. And by the way, this is why I've said this before on your show, and I really mean it. It's less it, it's less technology.

And what we're really just speaking about is how we do healthcare. My shift to becoming A-C-M-I-O and ACIO was not because I started out as an IT or technologist. It's because this is the way I deeply believe we're gonna do the changes in healthcare. It'll be predominantly through technologic breakthroughs.

Yeah. Whether it's molecular medicine, whether it's sensor, and whether it's deep analytics like AI and other tools. It's gonna come through technologic breakthroughs, but at the same time, at the end of the day, it's probably among the most human of behaviors we do, which is healthcare. So these things to me, are extremely wrapped up.

Your question to me is difficult to disarticulate because of how tightly they're wrapped together. So, so let's move down a.

The locus of care has shifted and it's been shifting, but we just had this pandemic. Has that accelerated the shift in where care is delivered and where we see care being delivered as we move forward? What are the ramifications of that to healthcare it? Like you said earlier about. Facilitating a, a meeting I really would like.

I, I, I wish we were at a meeting right now because I would love to become slightly controversial on this topic. I think where healthcare is shifting, you have to follow the money. I, I, I, I would love to be able to say we, we shift based on what makes the most sense and adds the most value, but . You, let me give you an example.

Ford Coles from the Advisory Board gave a great talk a couple months ago and he showed some data where while most of us achieved these unbelievable number of virtual care visits. The vast majority of us have returned back to some relatively low volume of virtual visits. Now, the graph had a peak someti somewhere up into the 70 and 80% of all ambulatory visits being virtual, depending on the organization, and those places have gone back down to something around 20% only, and that absolutely mimics Michigan medicine.

One of the reasons is that

we want to be sure we generate appropriate revenue for our visits. I think that the ultimate amount of virtual care will be based on what will be reimbursed and what will not. It's not just a professional fee. It'll also be the facility fees that ambulatory sites either continue to get or if they don't get, they're not gonna just continue to support a lot of virtual care.

Now that, I don't wanna sound overly cynical. I think virtual care is an incredible patient satisfier and provider satisfier. As you and I are talking, my wife is seeing patients. The other side of our house, and many of those patients don't have to drive eight and six hours for a 45 minute visit with her.

They love it. We don't want that to go away, but the locus of care is still going to be where payers are paying us to provide that care. So if we're going to shift this care, and that's an example of some of the pilot. Programs we're doing with some of the, uh, private payers to do true hospital care at home.

One of the most challenging aspects of this is to figure out the payment models so that doing this care and all the investments we need to do it super safely. Then efficiently will require the payments to model that shift in locus of care. The other one is then where is the efficiency? I don't study this so I don't have really precise answers, but what are the financial models for the cost effectiveness of seeing patients in a facility?

versus seeing patients at their home or some other locations. Bottom line is, I think we're going to see more virtual care, but I don't think we're necessarily gonna see the kind of expansion of virtual care that A, we saw at the peak of the pandemic, or B, even some people would envision we wanna do in this disruptive manner.

In part because. Who's gonna pay for it being done in this distributed manner versus that facility Follow the money? is, uh, I'm not sure it's cynical as much as it's just practical and we're seeing the healthcare associations and we're seeing hospitals and others make the case today to the regulatory agencies and, and to CMMS and others that, and, and, and to commercial payers.

If, if we truly believe that this is a more efficient and more effective way of distributing the, the care provider resources across a larger population, and we wanna keep that momentum going for telehealth, then then it needs to be funded. I'm not sure what the right question here is. Is there any way to do this other than government and.

For telehealth expansion, is there a model? It would appear that there is a model. 'cause you have, uh, you know, you have Teladoc, you have, uh, Walmart just this last week buying a, uh, huge telemed company. You have Amazon Care sort of coming into the market. It would seem like they're not basing their entire model on, uh, reimbursement from cms and.

I dunno, direction for a healthcare provider to build out that same kind of model? Or is that not necessary? No, no, no. I, I think it's a, it's a great question. I would say if you look back at the history of where telehealth has been very successful, it has started in areas that I'll use the term have had capitated reimbursement.

It has been very successful at the va. It's been very successful in DOD in the military. It's been successful in some areas that, well, prison systems. It's been very successful also in specific areas where it's been difficult to get care, specialty care, mental health care. I think. One of the things that will emerge out of our discussions around covid will be this enormous amount of recognition for the burden of mental health and the really successful ability to provide those services remotely or virtually.

In some ways, it's actually better than in person for both the patients and the providers. But to me, one of the key drivers is the just ongoing challenge of getting particularly specialty care out into remote areas. All of those, I think, will only expand because of this natural experiment, if you will, over the last year and a half.

But the other ones are where we already have. Uh,

capitated payment models or bundled payment postoperative visits are a great example where a virtual visit is only aligned with all the things that we're doing. Patients love it. They don't have to drive . And wait literally to be seen for two minutes because it's already part of a bundled plan. The providers can see more new patients and relatively quickly do a virtual visit.

So I think as we look at where those natural areas are, those will only continue to expand. In fact, they really hadn't expanded before because we just didn't have the catalyst that Covid and the pandemic has created. And from there. I think we're gonna see other things start to grow out. Well, patient visits, and this is where the disruptors really will put appropriate pressure on those a hundred year old healthcare businesses that have, well, of course I'll just have people wait in my waiting room for 45 minutes.

Yeah, no. You know, a lot of young people, a lot of young workers, a lot of companies. Are going to say, look, we're just gonna reimburse you to do a virtual visit with X, Y, and Z company because it's worth it. It's worth to us for you not to be gone for two hours to go to this old brick and mortar place to get their visit.

Those are the areas that I think we're only gonna see expand, and from that we'll get a better idea of what, what's gonna change. Let's sit on a, a couple regulatory things. The 21st Century Cures information blocking. Any, any, uh, where's this gonna lead us, do you think? Well, you know, it's funny, I got an email from a patient's mother just two days ago, and it was a patient who had cardiac surgery, a, a child who had cardiac surgery, and she was fantastic.

She was concerned about data in the patient portal not being there. And she said, look, I'm just reaching out to you. She didn't know me at all. She literally . Found the CIO's email and I was really impressed. So I got in touch with her right away and I said, listen, this is fantastic. Let me see what I can help answer with.

I'll connect you to the CMIO and all that. But fundamentally, what she was asking for were more data to be available because she, as she said, I am my child's advocate at the heart of I, I really wish the ONC had used a different term because. It's not about information blocking, it really is about interoperability and availability.

So I think that the push that the ONC and CMS are doing to, uh, encourage us as providers, payers, and even to incentivize third parties, is probably overall in the benefit of everyone. So I think that, like I said earlier, even with remote care, the. The catalyst for data, particularly with open APIs and open web services to be available, uh, also for innovation that will occur.

Anish Chopra has been really articulate about how the government, when they made data available, like TPS data or weather data, think of all the uses we now have for making those data available. I think ultimately that will be good. If I have a concern that I've expressed publicly and I've been.

Criticized by at least one or two CEOs is that it's not, I don't think of it as the CIO, as my data or the institution's data, but I do think of us as the, as the custodians of those data. I do think that the. Typical person does not really know or understand the depth of their medical data and that they seek a trusted provider, a nurse, a physician, speech language pathologist, it doesn't matter.

They seek a trusted professional to help them with their cherished really important healthcare data. I think it's complicated and there are data all over the place and that the average person, including even myself, would not, a less than average person, really understands the depth of that. So if I have a concern, it's, I would like us to go into it carefully and responsibly and not just open up.

Enormous portals of patient's data at the individual or the bulk level and have data migrate out, and then we start to learn, wow, that really wasn't good, that everyone now knows about this genetic marker that I have, and now I'm not insurable, or whatever, whatever. So I'm just a little bit on the conservative side of how we open up, not the idea that we do.

Of course that that would go against, other people would say, it's not yours to choose, it's the patient's they've given permission. I just, it sounds very paternalistic, but I just don't think the average person really understands the sophistication of their healthcare data. Yeah, and in the interest of time, 'cause you and I could have a whole hour conversation around that.

'cause I think it would be interesting. But I, I do wanna hit on, uh, one other regulatory and get back to the cloud real quick. So, price transparency. AHA contends, it's really hard to do. We have to put 200 shoppable services, the price for those online. I, I guess my question around this is the, you know, we've heard arguments that this is not gonna make any difference.

People are, aren't, even if they had this data, they wouldn't know, again, wouldn't know what to make of the data. It's not necessarily going to change behaviors in terms of making the consumer any more activated in terms of shopping for services, uh, thus the term shoppable services. My two part question on this is what, what makes this so hard and will it make any difference?

Or is it the foundation for making a difference later? You know, this is not my area of expertise, so, uh, I'm just gonna speak like an average civilian on this one. I think where services are elastic, some of these data may shift them. I just don't know how much. I saw a very cool app two years ago at a, uh, advisory meeting that I was at with UnitedHealthcare, as it turns out.

There was a insurance company that demonstrated with a really, really very user friendly app, the ability to find out the cost of a variety of services in an area. I don't know exactly how

accurate. Those costs were, but I'm gonna make a presumption. They were reasonably accurate. Or if they were inaccurate, they were reasonably inaccurate. Similarly. So if I have a need to get a skin tag removed from my, I'm gonna go to the place that's gonna do it at the least amount of cost and closest to me.

And so if I can just find an app. I can put that in and I can find out for you. You're charging me $125 and she's charging me 10. I'm gonna do that when I need a liver transplant. The price transparency is just not gonna be as important. And when I have a broken arm or I have a gash in my child's head, I'm gonna go to the nearest place.

And if they're gonna charge me double, I'm just gonna pay it. So I think that there's a certain degree of human. Behavior and, and the elasticity of the thing we're talking about that will drive that. And then of course there's the whole issue of the accuracy of the data. And I just don't know how accurate they are or not.

But I think those are probably at the core of, of where some of that comes in. Let, let's talk about cloud for a second. Thanks for that answer by the way. I, I appreciate it and I agree with you as an economics major, the , you, you explained elasticity of demand very well, but you know, as we look at cloud, you talked about this decision around the build versus buy.

You talked about the data center versus essentially cloud would be a, you know, pay as you go kind of model. It really is a very complex. Set of questions because cloud itself is a, is a significant amount of technologies. There's applications as a service, there's platform as a service, there's infrastructure as a service, and, and that's just the, the main aspects of cloud.

And then you have all these other, uh, sub components that you can really buy as needed and, and access to components as needed. And does the cloud represent more than just access to those technologies? Does it represent. A, a new kind of architecture that could potentially lead to more flexibility, more agility for healthcare.

Is that, is that one of the drivers, or is it financial? Is it access to those technology components? What, what drives the move to the cloud at this point? Yeah. I feel like talking about Jay Gatsby looking out at the future and all of the possibilities, I, I think. The reason why the cloud's both a great word and a terrible word all at the same time.

Is that it? I think it encompasses everything that you just said. So the, the way I would think about it is that there is no matter what an inexorable move toward applications, let's just start with applications being hosted outside of your environment and residing. Not on your device. The irony of ironies is we're moving back towards the hub and spoke model of computing in the eighties in a way, but now in a much more sophisticated manner.

So no matter what you want to do or not, you are not downloading, you're not buying your software on a CD or ADVD and you're not, unless so. Are you now even downloading that software via the internet to your device? You are using it in the cloud. Take Microsoft 365, just a perfect, simple, complex answer because you can't avoid moving towards Microsoft 365.

If you're a Microsoft customer and you've always been in the cloud, if you're a Google customer. Always have been. So that's a great example. So now take the infrastructure. Before we had to buy and maintain infrastructure to support our Microsoft tools, and now less so the EHR is the other one for us. In healthcare, we all will be moving to some form of a hosted version of our EHRs over time.

Whereas up until now, we've been spending millions of dollars. To replace our infrastructure, compute and storage and networking to run our EHRs. That's gonna change over the next five to eight years, and then we can start getting into more and more applications. So the way I think about it is in its circular, but I try to incise that circle and try to make some things, at least linear, is what is our overall application strategy?

Where are we moving, what are we moving to and when do we think we'll move there? Knowing that, how does that inform our infrastructure strategy? Do we continue to buy and replace on-prem or do we start using more and more of these services in someone else's data center, IE the cloud? Is it public? Is it private?

And I think that's what we're all seeing, a significant movement too. What I know on the other hand is it's not all things cloud. We're not moving every one of our services to the cloud. Some of our storage just makes a lot more sense to do it on premise. Some of it depends on the size of the institution.

As we have more and more consolidated health systems, it makes sense for outlying hospitals and clinics and practices to use the services of a health system, not necessarily consume it through public cloud. So I do think that these are interesting discussions. And then let's take an extreme. So I started raising this question to a few people.

Are you gonna, uh, build your own quantum computer? The answer should be, no, of course not. Are you con are you gonna consume the services of quantum computing? I hope the answer should be, I think I will. But will you do it primarily yourself or will it be. Part of the vendor application that you're using that will periodically reach out to cloud computing to do some computations.

They currently can't do that, I think is what we're gonna be doing. So in a sense, you're still using cloud services, so we, we could, I really could go on about this, but for me, the bottom line is, is it a data center question? Is it an application question or is it a business continuity? And a cybersecurity question.

Well, they're all together. Yep, absolutely. And cybersecurity.

Right. But Andrew, we're, we're up on the time and I respect your, your schedule here. So, hey, thank you conversations. The next time we.

I have this conversation, but I really appreciate you coming on the show. Thanks for being here. Oh, my pleasure as always, bill. Thank you. What a great discussion. If you know of someone that might benefit from our channel, from these kinds of discussions, please forward them a note. Perhaps your team, your staff.

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