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 Welcome to this Week in Health It where we amplify great thinking to Propel Healthcare Forward. My name is Bill Russell Healthcare, CIO, coach and creator of this week in Health. It a set of podcast videos and collaboration events dedicated to developing the next generation of health leaders. This episode and every episode since we started the C Ovid 19 series, and now that we've

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CLIP. N-O-T-E-S at this weekend, health it.com, and you'll be signed up to start receiving these to your in inbox. Okay. This morning we're joined by Dr. James Stalcup, the enterprise CMIO, and medical director for the Wilma p Mankiller Health Center. Good morning, James. Welcome to the show, Mr. Russell. Glad to be here.

Thanks for having me. . Mr. Russell. Wow. I, I appreciate you calling me Mr. Russell. I don't get that too often. I like to heap on the respect, uh, Wilma p Mankiller Health Center. Give us, give us some background and, and, uh, you know, on the name as, as well as, uh, the organization that you represent. Okay, so, uh, I'm James Alko.

I'm an md. I am a clinical informaticist. I am, uh, boarded in, uh, primary care, family medicine and in clinical informatics, and I work for the great sovereign Cherokee Nation. Cherokee Nation is the largest native American tribe in America. We are located in Oklahoma. Uh, our reservation 14 counties. 10,000 square miles.

We have nine big facilities, uh, including a hospital. We have . Now just finished construction on the biggest outpatient, uh, clinic. I believe that any tribal system's ever has a half million square feet. Uh, we have a geographically, very rural population, which leads us to have a robust health IT response, as you can imagine.

Trying to coordinate care across all these venues. And specifically in addition to being Chief Medical Informatics Officer, I am a clinic medical director of the great Wilma P Man Killer Health Center. Shout out to all the Wilma p fam. Wilma p Man Killer was female chief of the Cherokee tribe. She did some very, very wonderful kind of groundbreaking things, uh, for the tribe.

So very, uh, honored to be at the, what I consider the flagship. Clinic of the Cherokee Nation. We're 12 doctor clinic. Uh, we have optometry, onsite pharmacy, physical therapy. Uh, our clinics have a very broad spectrum of services. Even the rural ones, uh, have a very broad spectrum of services. So, uh, we, uh, have a patient population.

Active, uh, patient engagement every year, a better part of 200,000 total patient, uh, total eligible beneficiary population. Uh, somewhere over 400,000. We serve, uh, beneficiaries of any federally recognized tribes. It is not restricted, uh, just to Cherokee citizens. We are a compacted health system, which means that we are not an IHS site.

We do work closely with IHS, we do joint ventures with IHS, but we actually. Administer and deliver our own healthcare.

Is that geography? I mean, how did your system, let's start with how did your system experience Covid, uh, across such a large geography and how did you, uh, sort of adapt to it? Well, so this is interesting and it is, you know, here we are, um, you know, recording this in, in late June and it's still evolving.

And so we went through several phases, uh, of um. I would say the sort of human acclimation to the fear of covid arriving. So we had this early warning that it was happening in other parts of the world. And you know, kind of first, our first stage was denial. Well that's not gonna come over here, because everybody saw SARS and mers and we, we never really had to have a response to those.

You know, uh, the Navajo nation I know had a very, very, uh, heavy, uh, uh, unfortunate impact of, of Covid on their community. Um, so we were very . Proactive in how we handled this. And I will say, um, I don't, you know, believe in giving false praise, but when you do have the ability to give praise to, to something, um, you know, you should.

So organizationally, Cherokee Nation, you know, not only our health services, but our business aspect and there had a very, very, um, immediate, uh, very intense. Analysis of what we were facing. And it was daily calls, long before work started. Uh, it was work groups. It was, we have our own infectious disease, you know, departments.

Obviously that was a huge advantage. Um, it was as aggressive a response as I can imagine. And even now that we're able to look back, we are very, you know, thankful that we took the steps that we did. We knew that it was gonna be a very broad . Area of Oklahoma that we're dealing with. Um, but we'd done this for years and we implemented a lot of the things that, um, we needed to go forward.

Uh, so we had configured our network and tested, and we were doing telemedicine in psychiatry, dermatology consultation, uh, infectious disease consultation. Uh, we worked with IHS. Echo on our Hepatitis C program, which is just, we've got a great Hep C program. We had all of the bricks and shingles and tar paper and everything we needed on the job site.

We just had to put it together. Had I known the equipment requirements, I would've bought. Cubic yards of cheap cameras before they became impossible to get. Uh, this was one thing, you know, we, we never anticipated that we would need to deploy thousands of, of more webcams. Um, but we did have a framework and infrastructure so that we could convert any room in Cherokee Nation, any exam room, to a telemedicine room for about $35 and 15 minutes of work.

And that was a big advantage as we went through this. Um. Do you want me to go ahead and get into the, the framework of how we we handled it? Or should I Yeah, that's a great question. It's, it's interesting 'cause we had a lot of conversations and uh, you know, we talked about MacGyvering telehealth and it was, you know, the first time that healthcare really had to scale up that quickly around telehealth and, um, a lot of 'em ended up doing what you're doing.

But that was. Like their, uh, backup because mm-Hmm. some of the things we had didn't scale some of the, the costs, uh, the training wasn't done. I mean, did you have your training pretty well in place before Covid hit? Did you have a majority of that equipment already in place before, before it hit or did, did you have a response as well to scale it up?

So we had about a fifth of the equipment, uh, in place. If I was doing bar napkin math, we had about a fifth of our equipment out in the field. We did have good provider buy-in to noon meetings. Right. Um, noon meetings using teleconferencing because that's how we would push out education. So we already had provider, um, familiarity with that part turned out to be a big, uh, point, so.

What we did as this started ramping up is, you know, I went to my health IT department. This will be the meat. This is what everybody I think will benefit from. But then again, who knows? Uh, so when we started rolling out our response, I went to my Health IT team and I said, listen, I'm not an expert on C-O-V-I-D, but I think we have to treat these patients like a source of radiation.

And everybody thought I was crazy. And I said, look, if you have a source of radiation, what do you do? The first thing you do is you avoid it. You try not to have it around, but if you do have it around you use protective equipment and you try to distance yourself from it. So how can we distance ourselves?

Well, you know, the obvious answer is you do telemedicine to people's home, but there are some less obvious answers. For example, you can have a patient come into your clinic and go into an exam room. Then the nurse can perform the patient intake from a different area of the clinic. Using telemedicine from the site into the room, and now they're more distant from the patient.

They're not within six feet. Right after the nurse does the intake, then the provider can join the call and now the provider can deliver the . Patient care, the office visit to the patient while they're on site, and then if the patient's offsite, you have a separate sort of procedure, but it all results in the same thing.

You're keeping people separate. The patients were very fearful of covid and they liked that. They liked to be kept. Separate, uh, during this process, and it made it very scalable because the equipment required was so inexpensive and we did have it on hand that we were, we rolled out a total of 16 service lines of telemedicine.

I won't go through name in 'em all 'cause it'll take a while, but we rolled out 16 service lines of telemedicine. Including EMS pre-hospital, and all of them had slightly unique workflows, but all of them adhered to our basic Visio. And then to train the providers on how to do this. We had noon conferences.

Every day. Um, I, I can say that we used, uh, Microsoft product for that Skype for Business link. Um, and the providers, there was just an all provider, you know, all nursing email that went out and you could join every day if you wanted to. We had some providers that joined, you know, eight days in a row. Uh, or if you got it the first time, um.

Then you didn't have to join again. You felt like you were competent, or if you needed a refresher, you could join. So that kept us outta the field. It kept, kept our IT staff out of the field going and doing elbow support or anything like that, and it was very, very beneficial to be able to provide that training.

Um, I think training was a big part of it because the pro, you know, we didn't mandate anything. We made it good enough that people wanted to use it. Right. What, what do you think is gonna live past the pandemic? I mean, one, one of the things I found interesting in our conversation is you had to think this way because of the Geo Geographic dispersion to begin with.

I mean, to get specialists into such a wide geography is, uh, incredibly hard. And I mean, do you think. Telehealth will live, uh, the, the, the amount of telehealth you're doing is gonna live past. Do you think some of those, uh, protocols of keeping a distance for intake and stuff are going to change or stay the same?

So there's a few things that I think will live past this, um, this phase of, I, I don't know if Covid ever goes away. I think it's something we're gonna be, you know, dealing with, concerned about for, you know, when I talk to my providers, I say, the remainder of your career, you're gonna be dealing with this.

I hope I'm wrong. Right. Hope I'm wrong, but hope for the best, plan for the worst. It's kind of a good mantra to have. Uh, the few things that I think are going to be ingrained, um, one of them is an ethical issue. Uh, and I'll kind of cover that last 'cause that's one of the more interesting points. Um, I think that knowing that you have the ability.

To put a patient in a room and deliver healthcare to that person. With the total in-person time, the total time that you have a staff member within six feet of that person, um, we're at less than two minutes. Chaperone takes that person, puts 'em in a room, puts a vital sign monitor on it. The patient calls out the vital signs, right?

We want that person out of the room as quick. Quick as we can in my facility, uh, seeing Covid patients, zero of our staff have contracted, uh, COVID through the course of their duties. Wonderful, wonderful. You know, kind of statistic, I think that once you have the ability to do that, I. Um, you are going to be willing to utilize that, uh, in other avenues of infectious disease, right?

There's gonna be more commonplace that you can deliver care outside the exam room. I believe that it is going to push telemedicine regulations forward. I. They may be scaled back a little bit as far as the payer side, but I think that there'll be permanent changes to the way we view, uh, telemedicine. I think that having hardware on hand for responses, you know, one of the coolest things that you can do is, um, Mr.

Russell, let's say you got a clerk and the clerk has to welcome people to the clinic and check 'em in, right? Uh, you stick a Kindle on a stand, you have that Kindle run, whatever platform you want to over your network, and then you put a Kindle in the back and now you've just replaced that video audio communication.

Um, it's hard to have an original thought, but here's my original thought. Um, a patient. Who has autonomy? Part of the patient's autonomy is their choice in how to represent their concept of self. So you're choosing to have a Zoom call with me, and I am respecting that That is you. That is yourself.

Aristotle would say, you can't remove the ability to cut from the knife. It's no longer a knife. So this is your concept of self. I believe that that's you. I, I respect it. Right? Um, if you call me on the phone, same thing. That is your choice in, in, um, in how to represent yourself. I believe in the future there will be an ethical consideration that says, refusing to accept and agree to a patient's.

Desire to represent themselves electronically will be seen as a violation of the patient's autonomy, and then it's ethically prohibited. You cannot violate the patient's autonomy. And as I've brought this up, I've had people who were critics and they said, look, you can't argue that you have to let a patient do video telemedicine because it's their concept of self, because you may not have the technology to do that.

But if you are going to operate on someone, you have to get a consent form and your argument can't be, we don't have the ability to provide a consent form. Right. So I think that as we go forward, there's gonna become big ethical IT issues in how you actually deliver care. Like, do you allow that person to get care?

Are we gonna have systems that refuse to do it unless it's done a certain way? Um, there is a, you know, consumerism is a big part of this, right? So the market may favor systems that use telemedicine, but I believe that at some point it'll become so ingrained that you're not really allowed to make a person.

Insert a nozzle into a vehicle and put fossil fuel in it to get in it, to drive up to your facility, just because that's how you respect their concept of self. And that's kind of a, it is a, it's a, I know it's an esoteric thing, but down the road I think it'll happen. I think that's gonna be a big issue.

No, I think that, I think that's huge. I mean, it's. Yeah, at its simplest form it is consumer, consumer choice, but you're actually raising it to an ethical, uh, level on the ethical standard, which is, which is interesting in and of itself because when you were talking about setting up that room where the, the clinician comes in and whatever, it sort of dawned on me as you were having that, and I'm sure thinking about it.

But, um, yeah, the reason the patient doesn't wanna see the clinician is because. They're, they're a potential carrier of the disease. And with our limited understanding of the, uh, safety protocols that go on in hospitals, uh, some people might even consider a clinician who is moving from room to room, patient to patient, those kind of things, to be a high likelihood carrier of 19.

And so, yeah, I. I could see myself saying, look, I, I, I don't want to come in contact with you. This is how I want to receive care. And yeah, you, you have to adjust to, um, essentially just a, a new norm, a new, if Covid is with us. Forever, then we are going to have to rethink a lot of the things we have done in the past.

And, uh, uh, you know, I I actually to close, I mean, because , we've, we've chatted for a while here, but the, the thing I wanted to to ask you is you purposefully, I, I think creativity happens in constraints. Right. The most creative people in the world to me are the people on license plates who like, say a complete sentence with six letters or seven letters.

And you're sitting there for, you're sitting there at a stoplight, you're reading it, and all of a sudden you go, oh gosh, look at what that says. I super Twitter. Yeah. eight characters or whatever, seven characters. It's amazing. I'm, I'm with you on that by, I mean, I, I look at it, I love it. I'll just stare at that license plate.

So, yeah. So you have, you have a set of constraints that you said, look. We have this geographical constraint being the geography is so large, you probably have some financial constraints where you said, yeah, we're, and. We're gonna, you know, do a Cadillac service at a, I forget what, what is the VW price?

Craigslist price. Craigslist Price. That's the only thing I could think of. I dunno if you know this, but VW prices now are pretty, uh, pretty up there. But the, uh, but yeah, but outta Craigslist price. So you have those constraints. Defining those constraints is powerful 'cause now you can step back and go.

Okay. Commodity hardware, uh, we're gonna utilize readily available, commercially available, um, communication. Uh, software that we can do a video visit just like this. We can, you know, zoom in, get enough quality, those kind of things. Most phones, we were talking earlier about cameras, and you were talking about earlier on your podcast, you were using a certain type of camera.

Then you went to a GoPro. It's crazy 'cause I found that the best videos I shoot come from this little device. And you know, that same thing is probably true in healthcare. I mean, are there that many cameras that are, every patient has a, um, every patient has a telemedicine station in their pocket. Uh, smartphone penetration is very high in rural populations.

Um, I can tell you that rural and non-white populations are more likely to be reliant on cell signal as the only form of internet. So that kind of adds credence to the argument of using the cell phone. When we predict who will use telemedicine, we take a map, uh, of the visits by zip code from different zip codes, and then we look at the broadband availability, and then we look at the carrier cell availability.

And that's a good way to kind of, you know, estimate where people will be eligible for services. And, and just to your point, um, using a. Using a mobile device strategy as well as your onsite strategy. Uh, there's a lot of people who kind of talk about telemedicine who are hobbyists. I don't wanna call 'em hobbyists, but you know, it's not a big, you know, we had seven of our past nine weeks, we had more than 50% of our visits done by telemedicine across all 16 service lines.

So this is, you know, a very big, it does work. Um, people are happy with it. Uh, people don't know they want rich communication until the first time they do it. They think a phone is all right. But once you give 'em phone with video, they love it. They come unglued. Uh, when we had, you know, when I've done it working from home, they like it.

Now they're kind of like, this is a doctor's house that I'm, you know, I don't know what it is. There's something like, it's a more intimate thing, but I'm gonna say, Mr. Russell, I forgot to say this earlier. For those people out there watching this who are gonna do telemedicine, allow your providers a way out.

Allow them a way out on every visit. So, . On our sites, we have, uh, escalation provider. This is a doctor on site whose only job is to do visits that are escalated. Less than 5% of telemedicine visits are escalated, but when you have somebody with abdominal pain, they're worked up in the room, all the labs are done, the radiology's done.

Then our remote provider or virtual provider pings. The onsite escalation provider and said, Hey, I want to escalate one to you. They have this, this, this. That provider then goes in, does the procedure, does the physical exam have a way that your providers can escalate the patients that need? Uh, in-person care, and then you've removed 99% of, you know, I mean, people are unfamiliar with technology, I get that.

But if you allow them a way out, a way to escalate a patient, then you've just removed their fear. I'm not scared of the technology. They're scared of having somebody who needs in-person care that they can't get the care the patient needs. So that's my pro tip. Pro tip, give 'em a way out. Uh, I lied. I'm gonna what, two more questions.

One is broadband. So broadband cell access. Uh, somebody, an article I just covered was talking about broadband's really now defining the haves and the have nots in our society. Do you have large sections of your geography that. Either are, are not covered by broadband or not covered by cell signal? We do.

We, we do. We have, um, you know, cellphone coverage is kind of ubiquitous, right? We have more trouble right now with, uh, state medical board regulations than we do actual availability of some degree of coverage. So we have had patients who have driven down the road to park somewhere. So that they could have a signal so that they could do a telemedicine visit, you know?

Um, it's uncommon, but it does happen. Uh, but we do have areas that do not have adequate broadband. Well, we would consider adequate broadband for video telemedicine, but these same areas are areas in which people have figured out that, you know, that, that four GLTE, you know, connection on their smartphone is better than the availability of internet in the community a lot of times.

So they just choose to use that. Yeah, absolutely. I wanted to come back to your YouTube channel 'cause you're, you're doing a great service to the, uh, community talk. Talk a little bit about what you're doing. Okay. So, and this is gonna be a ten second, I'm not gonna like plug it for a long time, like ten second, you know, little sales pitch.

So I teach interviewing. I. Right. I'm so impassioned about teaching people how to a job interview because it's which, which, which side? So the interviewee or the interviewer. I teach you how to walk into a job interview where you're trying to get a job and out compete everybody else who's gonna do it because Mr.

Russell, it's the only way you can have a superpower on this earth. Like if tomorrow, if you decide to become a grandmaster in chess, it ain't gonna happen. If you decide to be a a world world champion boxer tomorrow, it ain't gonna happen. But regardless of your innate skill, you can be a great interviewer.

And the reason is. 'cause nobody tries. Like nobody don't, nobody learns how to interview. Um, I've done a bunch of interview. I don't even know how many mock interviews I've done. I've interviewed a whole lot of people in real life and I used to teach doctors, here's what you need to do in an interview. Um, it, it got kind of popular.

So we started making videos and got an online YouTube me course, but it's, uh, the YouTube channel is just James Stoup, S-T-A-L-L-C-U-P. You'll see me on there. I got a killer mustache in the videos, like a gimmick. Um, but yeah, just developing personalized content and figuring out how to deliver it. If you, I'm talking to the people who are going to a job interview.

If any of y'all out there think you're gonna go into a job interview and be yourself, you're gonna get beat by somebody who knows what they're doing. Um, your job is to develop, memorize, learn how to deliver personalized content, and then you're gonna go in there and kill it. It's so easy to dominate a job interview.

I don't know. I. Well, I, I have no idea how somebody spends all these years of their life developing a skill and then doesn't even try to learn how to interview. Well, I'll tell you what the, um, gosh, we can have a whole conversation on that. I, I've, uh, worked with people on their resumes now. Mm-Hmm. . It's one of, I put out a LinkedIn post saying, Hey, I'll, I'll help you if you, if you're looking for a job, I'll help you.

You know, I'll, I'll forward your stuff around or whatever. And a bunch of people ask me to help with their resumes. I their resume. I'm Okay. First thing you need to understand is the resume. Is a sales document. Mm-Hmm. . And it's gonna be sitting there with 50,000 other sales documents. So you have to figure out what you're trying to sell and, and that's what you need to hit.

And you don't need to talk in terms of, this is what I did, then I did this, then I did this. You need to talk about what you create for the organization. You know, I delivered this, I delivered this, the organization moved forward. This, because when I'm reading it, you gotta think it, think it through from the other person's eyes.

When I'm reading it, I'm sitting there going, what can you do for me? Right. I mean, it's, it is almost that crass, because again, I'm, I'm reading a thousand, uh, this is not an exaggeration. There was one job we got like a thousand resumes for. Mm-Hmm. . How much time do you think I spent with each resume? I mean, if I spent, if I, yeah, if I spent a minute with each one, that's a thousand minutes.

Uh, I'm the CIO of an organization, I can't do that. So essentially somebody else sort of calls it down and then I'm flipping through 'em going, yeah, yeah, yeah, yeah. And it's interesting 'cause you're just, you're just pulling out, I mean, you're, you're really pulling out snippets. It's a sales document.

People think I'm gonna write, they spend too much time on it, and they go, I'm gonna get the job for my resume. No one ever gets their job from their resume. Right? And you know, the, so this is a good point. Nobody ever gets a job from the cv. You know, you've seen my cv, it's an infographic. I've just got an infographic for my CV because when I send it out, they've never seen an infographic, right?

Nobody's getting it because they're the most qualified. They're getting it because they endear themselves to the person conducting the interview. They're the most liked. If people like you in an interview, they will figure out a way to hire you. Yes. So that's one of the big thing. You know, I've so many professional people, I know doctors are the worst about this.

Um, and doctors are in high demand and that kind of promotes laziness. But I've known doctors that they were like. I've done this, this, and this. I'm just gonna go in there and they're gonna know I'm the most qualified and I'm gonna get it. And I'm like, yeah, but somebody who's really got an impassioned story about how good they can barbecue is gonna go in there and beat you.

And then they do. People walk in there and beat 'em and they, I have no idea why I didn't get it. You didn't prep, you didn't do it. I mean, I'll tell you the other thing. When you get to the CIO level, when you get to a higher level, you're gonna interview with multiple people and doing the research ahead of time.

Like when you're, you're sitting down with hr, that's, they're looking for something a little different than the CFO's looking for, than the CEO's looking for, than, and you almost have to figure out, it's like, okay, again, from their perspective, what does the HR person wanna hear? They want to hear somebody who really has a, you know, a certain approach to, uh, managing people, to being with people, to caring for people, for following the.

The guidelines that are set out by hr, I mean they want to hear those kind of things. CEO's gonna assume you have those things. They're not gonna ask those questions. They're gonna ask, Hey, strategically, do you really know your your space? And can you move the organization forward? CFO's gonna want to know, Hey.

Are are, are you somebody who just thinks that we should just spend money willy-nilly? Or are you somebody who is creative and finds the best solutions for the, for the right cost? I was an E, an EHR, uh, CMIO bootcamp, and it was so funny. I was like, why would an EHR company put on A-C-M-I-O bootcamp? But they invited me.

So I went and about five minutes in they said, listen. Your job is not to police the finances of the organization. It's to find the EHR solutions you like. And I said, yo fam, y'all are getting lied to. You need to say no. 99% of the time you will run out of money. You will bankrupt your organization if you're buying everything that comes along, if you get one out of four of these things implemented with any sort of outcome, success, or any sort of benefit to the patients, I'll be surprised.

And um, it was quite the hot button issue. I ended up leaving that EHR conference in a . I threw a hissy fit. I stormed out, forgot my iPhone charger, and walked back in and get my iPhone charger. And it was quite the, and, uh, we have a, I've got a, um, I've got a guy who works with me. He's a pa, he's awesome.

He's like assistant CMIO. We're kind of working through the job title right now, but, um, in the middle of the hissy fit, his name's Jonathan. He's a great guy. Super good at usability. Middle of the hissy fit. I was like, I'm outta here. I've had enough of this. And I was like, but Jonathan's gonna stay a long time.

He was like, it was a, it was a week long. He was like, I had a week of sitting there having to put up with all these, yeah. . Well, it's a, you know, Hey, thanks. Thanks for taking this time. I really appreciate it. That's all for this week. Special thanks to our sponsors, VMware Starbridge Advisors, Galen Healthcare Health lyrics, Sirius Healthcare and Pro Talent Advisors for choosing to invest in developing the next generation of health leaders.

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