MD to CIO - Making the Transition with Joel Klein, Lee Milligan & Stephanie Lahr
Episode 36924th February 2021 • This Week Health: Conference • This Week Health
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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 I. A channel dedicated to keeping health IT staff current and engaged. Today we have a fun one. We have a conversation on what it takes to go from being a physician to being ACIO, and we have three great guests with us.

We have Dr. Lee Milligan with Asante Health. We have Dr. Stephanie Lar with Monument Health, and we have Dr. Joel Klein with University of Maryland Medical System. We cover a lot of different topics. Great conversation. I love this panel. I hope you'll enjoy it as well. Special thanks to our Influence Show sponsors series, healthcare and health lyrics for choosing to invest in our mission to develop the next generation of health IT leaders.

If you wanna be a part of our mission, you can become a show sponsor. It's really easy. The first step is to send an email to partner at this week, health A quick note, we launched a new podcast. That's right, a new podcast today in health. It. We look at one story every weekday morning and break it down from a health IT perspective.

You can subscribe wherever you listen to podcasts, apple, Google, Spotify, Stitcher, overcast. You get the picture. We're everywhere. You can also listen to it at today in health If you're new to the show or returning after a while, we now do three shows. On Monday, I get together with a peer and we break down the news stories from the previous week.

On Wednesday, we do a solution showcase or an influence episode, and on Fridays we absolutely do an influence episode just like this one where we talk to those who are influencing the use of technology in healthcare. Be sure to check back often for more great content. And now on today's show, today we're going to do a special podcast, one I'm really excited about for several reasons.

One, I love the topic. We're gonna take, uh, a look at what it takes to go from being a practicing physician, an MD to CIO. And uh, we've titled this MD to CIO, making the transition. We have three great guests, all doctors. We have, uh, Lee Milligan with Asante Health. Stephanie Lar with Monument Health, and Joel Klein with University of Maryland Medical System.

Good morning everybody. Welcome, welcome to the show. Morning. Morning, bill. Morning. The, uh, so we, we've got, we've got a lot of different ways we can go here, but as a way of introduction, let's, let's just start with. Te give us a little background on your health system and your area of medical practice and your impetus to be the CIO and, and I say brief.

'cause if, if we all share a 10 minute story, we'll be 30 minutes into it. So, and, and I want, I want to get into some of the brass tacks of, of what it takes to go from one to, from MD to CIO. We'll just go in that same order. Dr. Milligan, do you want to kick us off? Yeah, good morning Bill. I think just kinda looking back on my trajectory, you know, I didn't start out trying to become ACIO, you know, I think in the beginning it was simply about trying to understand this intersection of healthcare, uh, and technology, and recognizing that there was a train wreck about to happen between the industry, the medical industry, and the technology industry, and recognizing that there was opportunity there to make it better.

And so for me it was really about just trying to understand where we're going with this and trying to incrementally make it better. So I started out on the informatics side really being a trainer, really trying to understand how to use technology and turn around and teach the other folks how to use it better.

And that kinda led one thing to another, to another. And so. And the interest of not taking up all the time as you described. I'm gonna leave it at that, but it started out just trying to make the system better. What, what was your area of medical practice? I'm an ER doc by background, although I've done urgent care, I've done some primary care, and now I do telehealth, actually.

Fantastic. Stephanie, how about you? So I, I think probably a pretty similar story to Lee's. I finished my, uh, residency training and went into private practice as a hospitalist in, in Coeur d'Alene, Idaho. And at the time they really, uh, were just beginning kind of their EHR journey and certainly didn't have any physicians who were.

Even willing to talk to them about it as they told me. So I came into an interview, met with this, the CEO of the organization and was like, Hey, what, what EHR are you using? I'm a believer we gotta do this. And he was like, who are you? And what are you talking about? Are you sure you're a doctor? And. And I was like, yeah, I just, you know this, I really think this is where we're gonna be going.

And so they said, great. Yeah, we'd love to have you talk with us. And that talking became sort of a advising. And then that advising became a part-time job. And I was a hospitalist by clinical practice. And so I obviously intersected with a lot of the other specialists around the hospital. So then it was, okay, well would you, would you talk to the other doctors too and kind of get some, you know, information from them?

And then it just evolved and evolved. And then from the CIO perspective, you know, the organization that I'm with now at Monument, I came here about all, just about five years ago as the CMIO and, and now I have the combined or dual titles. My pre, the CIO predecessor, uh, was retiring and as I had conversations with the other senior leadership team, they felt like the CIO and the integration of technology in healthcare really demanded somebody with

Clinical knowledge and expertise to continue forging that path. And so they said, Hey, why, why don't you just, let's just add another title to what you're doing. And so now I do the combined role. So, uh, you, you know, you know Stephanie, there's still some other titles we can throw in there, like Chief Digital Officer, chief Innovation Officer, so we can.

We can really round out your, your title with, with lots of lots of acronyms if you wanna keep going. . Um, we'll definitely talk about that , Dr. Dr. Klein, uh, tell us a little bit about your system and, and, and how you became ACIO. Sure. So we're the University of Maryland Medical System, 14 hospitals, 28,000 employees, hundreds of outpatient practices, one big academic, you know, quaternary care flagship hospital in downtown Baltimore.

So I'm also an ER doc. I trained at the other big system in town at Hopkins and then was hired by a, what is now one of our big community hospitals. But, you know, 20 years ago was a little independent community shop in a suburb of Baltimore. I was the night guy, Lee. I'm sure you know what that you know is all about.

And I, after a couple years got elected to help run my group and eventually to run my group. And one of the early problems that I had to deal with was how to divide up the incentive compensation pool. I. For 60, you know, detail oriented type A people. And it had been based on, you know, what were thought to be metrics, but it was pretty badly done and I wanted to completely redo it.

And that meant getting data on things like your, you know, your turnaround times and your throughput and understanding how views should be attributed and, and, and all of that kind of detail. And to figure that out, you had to have data and to do that, you had to get into. What was then some pretty awful IT systems.

So I'd always liked that stuff and you know, I'd always tinkered with programming and whatever when I was, you know, in college and high school. But at this point it was, you have to do this to, to, you know, to make your group happy. And that in turn led to, you know, lots of relationships in it. Then when we put Epic in, you know, almost a decade ago, I was, you know, a big part of that.

And then would you help with the next hospital? And, and now I have this role. So that's, that's the brief version. Yeah. So fantastic. And, and wow, you guys are fantastic. Uh, following instructions, hard to believe that we got through that in, uh, only a couple minutes. Uh, because you guys have fantastic resumes, fantastic background.

What I'd like to do is really open it up a little bit more and have this sort of be a discussion. We can talk to each other, you can ask each other questions as you, as you sort of progress. I, I have a handful of questions that I think will, will keep us going. So I'll play referee and, and throw some things out.

First thing, just for all, what aspect of the role were you concern you may not be? Prepared for that. You didn't have enough training or, or background for as you stepped into the CIO role? Who, who wants to, uh, kick us off? I can hit that one. I'm happy to talk about what I don't know. . So, so I, when I first came in to this role in particular, I was really concerned about the financial aspect of it.

How to, you know, I, I went from a scenario where I had . Four cost centers to one where I had 22 cost centers. And you know, we're not a huge system. But you know, my, my annual budget with CapEx and opex is about 50 million, slightly more than my checking account. And so I was trying to, uh, get my head around how to navigate this effectively, not only to be detail oriented for the, for the numbers, but really how to intersect with the other executives on the team so that they understood that it, uh, was really looking at this seriously and that we were being good stewards of this money being allotted to us.

And that wasn't an easy challenge. There was a lot of, uh, reticence to accept it. Actually looking at this money as, you know, money from the organization that's gonna be allocated towards this business proposition versus this pot of money that it is somehow using. It was kind of an odd dynamic when I first came in, and so I tried to flip that on its head.

I try to focus on transparency and I try to focus on specific areas where we could identify opportunity, take action, and then really call it out. You know, as my dad used to say, you have to do good work, then you gotta showcase. You did some good work. And so I spent a lot of time doing both of those things kind of out of the gate.

But financial was big for me. The other big one, of course, was security. I've spent a lot of time studying security over the last few years. You know, at the end of the day, at least in my system. If we have a security breach, it's, it's really on me. I, I'm accountable for that. My team's accountable for that.

And so I really felt like there was an area I really need to understand much better than I did coming into the role, and I continue to try to, uh, augment that. Yeah, I would echo a lot of what Lee is saying. I think, and I, I know Bill one of the. Topics that we may cover is the evolution of, of medical education as, as physicians take on other kinds of roles.

I don't feel like even in private practice as a hospitalist, I really ever got to understand the . Interworkings of the financial aspects of, of the health system. It's just not something, as physicians, we typically get a lot of exposure to, certainly physicians that are in, you know, maybe private practice of a, of a clinic or surgical practice or something may have some more, but it's so much different and more complicated when you're start talking about a health system, you know, managing budgets, the.

The buckets, which can go in which bucket, the nuances of it, the tax implications, and not only that, and then just the process of what needs to happen when I certainly was . Feeling like, you know, I relied very heavily. I had a very strong team with a lot of directors with years and years of experience in, in doing that, and I relied heavily on them for that.

I think another element beyond just, you know, the security is one element of just that, the more technical side, again, I came into it with more of an informatics background. I got board certified in clinical informatics. I, I knew more about sort of the backend technical side than I thought I did, but I felt like I probably didn't know enough about that.

I certainly don't have any, you know, background in I. In computer sciences or anything from a, from a educational perspective. So I was nervous about whether my technical knowledge would be enough to help support the fantastic technical teams that I have in making sort of more complex conversations. So that's probably the one that I would add in addition to what, uh, Lee was already talking about.

Yeah. So go ahead Joel. No, I was just, I completely agree with. With both Stephanie and, and Lee. It's not, you know, a lack of, it's, it's, I mean, obviously the technology can be intimidating, but, you know, we all have good teams that, that can help us through that. For me, you know, it had to do with you're not gonna be able to manage in the same way that you've always managed.

I mean, we have close to a thousand people in, in our IT. You know, solar system, if you include contractors and you're not gonna know all their names, you're not gonna know any, you know, all their, their kids goings on. And you're gonna have to not get involved in every little issue. And as a doc, that's hard, especially as an ER doc because.

You know, we tend to be pretty strongly opinionated and wanna insert ourselves where we think something isn't being done the way we would want to do it. And you just can't do that when you run a big shop like this. And you have to back off and delegate and allow people to, to do their job. And, you know, in, in most cases, you know, you, you get, you've got a great team who can do that.

It, it, it's just a matter of learning when to insert yourself and, and getting better and, and better and more sensitive about that. I agree with what I agree with what Joel just said. I just wanna add that was really well stated. I thought I would just add one additional thing I was thinking of as, as, uh, both Stephanie and Joel were talking is contracts and negotiating with vendors.

So that's an area that I didn't have any real expertise in other than when I go to Tijuana and I'm negotiating for a. A small ceramic cat . Besides that, I didn't have a ton of experience in it. And, uh, now every contract, every software and hardware contract that comes through our system, I have to sign the, the contract, uh, for it, and I negotiate with, with vendors.

And so learning that it's a steep learning curve, I think, at least for me, around how to negotiate effectively with . With vendors, and it's a, it's a little bit difficult because in, as opposed to today's world where you can go online and you can see across the board what people are paying for different products, when you're buying software, frequently you're in a black box and you're in this, this odd space where you're not sure if you're paying, you know, the right price or you're paying, you know, two x what this, the system down the street is paying for that.

And so, you know, learning how to effectively understand the negotiation tactics is really key. Yeah. So what I, I'm gonna give you, you talked about what you were concerned that you didn't know, but what's the, what's the best move that you made as you've made this transition, I guess? Well, you know, Joel, we'll, we'll start with you.

I mean, as, as you look back on your transition into the role, you probably made a, a fair number of moves, but what's the one thing you would share with somebody who'd

absolutely. Of the best things that you did for me, it's realizing you, you have to pick your people and you have to hire great people, and that means not necessarily living with people that you inherit. And, you know, that's really hard, right? Because a, you've, you've gotta recognize this person is or isn't working for me, and everybody's got strengths and weaknesses.

And if you're not objective about what those are, you could overlook something, whether that's institutional knowledge that the person has or. A ability to cut through problems that, that you don't even know about. And remember, this is all unfamiliar territory. You're, you're feeling your way through this forest.

But if you, if you settle for less than a players, especially on your leadership team, it, it drags your whole thing down. And, and once you realize, you know what, I, I have the wherewithal here to make some changes. It can breathe all kinds of new life in into your situation. I've done that now several times, and it, I, I'm trying to demonstrate to the rest of our team that this, this isn't just true, you know, at this level.

It's true at every level of the organization, and it's, I've discovered it to be transformative, not something I would've ever . Completely picked up on, in my, in my former role. Is that hard? Because you didn't come from a, so you'll have somebody who's over applications and somebody who's over all these, you know, you'll have security, you'll have a, a bunch of technology areas.

Is it hard to make those moves coming from your background or is it just, you know, is is it just building the right chemistry in the team that you were looking at? Well, I mean, I, I'm interested to see what Stephanie and Lee think, but for me. You first have to figure out if people are answering your questions, and if you re realize, if you get the sense that, that your questions are reasonable and they're not getting answered.

In a way that makes sense for you, or if you ask, you know, I'd like you to, to show me some data on, on whatever, and lay it out for me this way. And, and you don't get hung up on the, the details of formatting, but more, this is how I'd like you to organize your thoughts so I understand what you're trying to tell me.

If, if people can't do that. Then there's, there's something not making sense, and it's, it's about finding your own confidence and your own trust in your own ability to ask those kinds of questions and set those expectations. Uh, Stephanie Lee, building, building the right team. Yeah, so I was. Perhaps fortunate in that, uh, my transition to the CIO role happened a handful of months, um, after we had gone live with Epic and that was a, an organization-wide, big Bang, everybody kind of thing.

And about five months later, uh, was when I took over as the c.

Of a restructure. We had legacy teams, we had epic teams. You know, some of those kind of elements that were already demanding that we look at things differently and kind of put them back together in a new way. And fortunately, the CIO that I worked for at the time. Had the confidence and the wherewithal to say, Stephanie, you're taking this team.

You need to lead this restructure. And for me, that didn't, I mean, I have fabulous people on the team already. We had to re situate what some of them were responsible for and how they were doing that. But it, it did a couple of things. One, to, to Joel's point, it built my confidence that I could, I. Think strategically about how the teams would be best aligned, how we could best serve the organization.

It also then put, put sort of the stamp of Stephanie on, on the organization early on. It wasn't, for example, to Joel's point, taking what I inherited and then the those same expectations that I would then just follow in the footsteps of my predecessor. Because from the very beginning we really shuffled things up.

There was change and with that I think, you know, my team would say, gosh, we don't look anything like what we used to, what we used to look like was not bad. It just, it is now very different 'cause we have a different kind of leader. And so taking those steps, I completely agree with Joel, was was important to sort of

Make, make the transition and, and kind of, uh, demarcate that, that move, especially since I was already with the organization and, and not coming in out from the outside. One thing, just to answer the first question, one of the things that I did right, as soon as I heard that I was going to be taking on the role.

Was I signed up for, uh, chimes, CIO bootcamp and that did a couple of great things for me. One, I went to the bootcamp thinking I'm gonna be a fish outta water. I don't know anything. I was, I was the only physician there at that time. They've, since I think, have more clinicians going through. But I was very nervous that I knew nothing and wouldn't, it just was, you know, it was gonna be at this steep learning curve.

And it reinforced actually, that I knew a lot of the stuff they were talking about already. The things that were important from change management and leadership, it was a lot less about the technology than it was about leadership. And so that built my confidence. The other thing it did was it gave me this immediate group.

Of colleagues and people to be able to draw on When I did have questions about security or I did have infrastructure questions or things that I was grappling with that I might not have as much experience in. I now had, you know, 20 some people that at any given moment I could shoot a message to and say, Hey, what are you guys doing?

And I really, really feel strongly about, you know, that collaborative group. Of having, you know, your, your confidants and colleagues is super, super important. Lee and I, you know, have conversed about a number of different things over the years and or with others and then brought them back to each other.

So I think that's super important. Yeah, I was just thinking back to reflecting a little bit back, back to when I was first asked to take on this role. My first. Conversation with my current CEO was his first day on the job. So he came onto the job and the very first thing he did as CEO was was hire ACIO.

And I had three requirements and had nothing to do with money or financial pieces at all. Really what I wanted was I wanted to make sure that I was set up for success. So I asked him for three things out of the gate. The first was I asked him for a coach. You know, could I, could I set up a framework where I could connect with a coach, somebody who's experienced in this field, who can help me navigate at least the first couple of months of this?

The second was I asked for a financial person. I asked, you know, can I bring on board somebody at least part-time, who can help us kind of navigate through this? And the third thing I asked for, coming back to what Joel was talking about initially, was, do I have the ability to build my team? Do I have the, the latitude to really make strong decisions to get us where we need to get to?

And he agreed to all three of those. And so kind of outta the gate, I was looking at that framework. I ended up doubling the number of directors I had. We had two directors. I doubled it to four and restructured a few things kind of outta the gate. And then the challenge was really understanding how do I keep what's working?

And then get rid of e eject. What really isn't working. And that's a delicate thing to do because as Joel pointed out, there are times you just don't know what you don't know about things when you're asking questions, at least in the beginning. And so trying to figure out who really has that institutional credibility, that institutional knowledge, who is solving problems that I don't understand right now.

And as this . Float on for a bit. I, I found myself challenged with a couple of scenarios. There were some scenarios where I was pretty convinced I was gonna have to let certain people go, but at some point in the process, I realized that I hadn't been fully clear with my team about my expectations. And so I sat down with a few folks and I, I was really clear about my expectations.

I clarified it for them, what that looks like. And I have to say, at least so far since doing that, that's really made a big difference in terms of how the leadership team is performing. Fantastic. I, my, my next question's gonna be around your medical background. Uh, how does your medical background help you as ACIO?

How has it potentially hindered you as ACIO? Uh, I'll give you a second to. Eli Tarlow and Sirius Healthcare. Sirius Healthcare is the sponsor of the show, but also Eli, who's the brainchild and really brought this group together. So I, I really appreciate working with Sirius and the, the great people they continue to connect me with, which is some of you guys.

So let, let's talk about that, that medical training. You know, it, it's, it's not been, uh, seen as positive when physicians go over to the administrative side. And I've been in rooms where I've seen the fact that, uh, CIOs don't really understand the medical, uh, side of it has been a hindrance as well. So talk a little bit about, uh, the, the benefits and maybe even the challenges of being a doctor as on the administrative side.

So when I came to Monument Health as the CMIO, I was new to the organization and new to the administrative team, and I was more nervous about that than, for example, the previous organization where I had would say I grew up both clinically and administratively. There was total acceptance of that because I was known first as a.

Clinical colleague and had built that trust and then the administrative part came secondary to that. And so people were like, oh, well that'll be great 'cause she's doing all the stuff we don't really wanna do anyway. And let's us sort of keep our clinical stuff going on. When I, when I came to Monument again, I came in, I, I have not practiced medicine since I got here almost five years ago.

It's weird for me to say that it was not the intention, it's just sort of how things evolved. Especially as I, you know, initially came into an epic . Migration, which was super intense and then took on the secondary role of both CIO and CMIO. Something sort of had to give, and I would say actually the clinicians that have were maybe surprisingly accepting of that process.

A, I use my clinical knowledge all the time in conversations in going to bat over different situations. Even in addressing things like when we have an unexpected outage or downtime, there is always a clinical thread going on as to what are the impacts? What do we need to do, and how are we gonna make it better?

And I think I've, you know, I've demonstrated that enough times that I don't get a lot of the. Well, you don't practice anymore, and so you don't really, you're not, you're not credible because I, I think that they realize that the clinical experience that I've had and that I continue to thread into what we're doing, I.

Brings value. And so in, and I think in general, physicians are, many physicians have no desire whatsoever to move into an administrative role. And that's great. 'cause if all of our physicians move into administrative roles, there's gonna be nobody left to take care of patients. And we already have a physician shortage crisis, so we need lots of physicians to stay physicians in clinical practice.

However, if we don't have physicians. Moving into these administrative roles, I think we, what we were starting to see was a real chasm between the clinical side and the administrative side, and that they were almost like against each other. And if you can do integrations and bring clinicians, whether it's physicians or other kinds of clinicians into the administrative side, I think we rebuild those bridges and the understanding and

So I think within my own organization we have several physician administrators, and I think that has been very positive and well accepted and actually really unifying. So I guess the way I would think about it, bill, is I think everything's got upsides and downsides. For me, the downside of being a, a, a physician in an administrative role is that you can overdo it.

So you can overplay the hand of, I'm a doctor and I know what I'm talking about, and so how about you, you know, kind of buzz off and that that's a real, that that is a thing, and it, it, it can be used for good or for not so good, and you have to. Calibrate that and you have to choose when you're gonna play that card if it's used correctly and used bely for the, you know, on behalf of our patients and our workforce that, you know, think about what everybody's trying to do right now with the pandemic.

I. Y you can advocate for a lot of the right things with the voice of someone who's been there, but if you overdo it, it's, it's just awful. And, you know, I think we all have colleagues, uh, who, you know, who are physicians particularly who, who do that all the time. And so you, you just have to have a lot of self-awareness.

I also think as a physician, you, one of the dangers is that you forget about all the other disciplines. So you'll look at things from a physician point of view and not necessarily a nursing or a therapist or a registration clerk or a, you know, CDI person or whatever it is. You, you have to remember, you're taking care of all those people now too.

And so you, you have to, and, and, and you have to remember that they will see us in these roles and think, great. They're, you know, here we are getting marginalized again, because our point of view is, is being. Relegated, you know, once again. And so you have to, you have to confound all of that. But I think the upside is pretty huge.

You know, if all of us, I'm sure have had colleagues who are grumpy about being asked to do something, you know, in some IT system, and if you can say, listen, I, I eat from the same bowl that you do. I know exactly what you're talking about and it's not that bad. Trust me. Let me show you. You know, that kind of language from a colleague, it means a ton.

I think it also helps us shut down some goofy ideas that, that get thrown our way. I think, you know, I'm, I'm sure all of us have, have been asked to implement, you know, things or systems or projects or whatever that might've, you know, seemed like good ideas to the person that came to you with it. But in the big picture, not what we should be working on right now, at least.

As a doc, you can, you can be a little more firm in saying no. And that's a big part of our job is to say no to stuff. So I think it's, it's got upsides and downsides, just like anything. And it's being self-aware of who you are and what you're bringing to the world that I think is most important.

Fantastic. Uh, Lee, any any thoughts? I think you're on mute, Lee. Yeah, mu mu phobia, that's the fear when you're gonna uh, say something really profound and be on mute, , and then forget it. . So you guys said it really, really well. I have very little to add to it. I appreciate how, how you guys both framed it up.

I think going back to your original question, bill, you know, I think some of the attributes of a physician that really help you in this role include a curiosity. They're really trying to pick things apart and understand things. 'cause that's, that's, you know, half the battle sometimes really understanding the problem you're trying to solve.

And the second issue I think that physicians are, are particularly inclined to do well at is prioritization. I think we understand when something's an emergency and when it's not. And we understand how to prioritize things in a way that's very intuitive and. So that's a big piece of it. And then going back to what Joel said, a little bit about the physician's perspective, one of the things I noticed outta the gate in this role and is in the CMIO role prior to this, was that there was an expectation that I would always take the physician side no matter who else was in the conversation, particularly as Joel pointed out, other clinicians.

Ts PSRs, other folks who are in this space doing good work but aren't represented. And there were times when the physician's perspective was frankly wrong, and there were a couple of key scenarios. One in particular where I took a very strong stance in support of the nurses. That, uh, was an awkward moment, I would say, for my career and also for the, that particular scenario, but ultimately, ultimately proved to be really influential and, and helpful in terms of moving the conversation.

And so now I, I hope, my hope is that folks understand that I'm gonna represent what I think is the best idea, irrespective of, you know, what branch it's coming from. Were there any preconceived ideas about it coming into the role that were sort of blown up after you've got into the role? I'll, I'll, I'll try that one.

I did not realize how incidental computers are to the whole thing, so it's just like managing anything else. It's just like leading anything else in a hospital or any other big organization. So, as an example, you know, all of us, I'm sure have have done projects around care standardization, where we're trying to get everybody to take care of the hip fracture or the

Knee replacement or whatever in a, in a more consistent reproducible way. So there's less clinical variation and, and therefore better, more consistent outcomes. And there's, you know, all kinds of tools available in, in all kinds of systems to help with that, whether it's order sets or care paths or clinical pathways or, or whatever it is.

And you have to be familiar with all of that. Really that's not the issue. the issue is change management. And do people wish to change what they're doing or are they gonna sit around and say, yes, but you don't understand, my patients are different. It's the art of medicine and all that, you know, that whole line of, of argument, that's what it's about.

And in that sense, again, it, the, the computers are incidental. You, you have to know what the tools are. More than anything. You've gotta know people, you've gotta understand how people think. You've gotta have some emotional intelligence. And if you don't, if, if you can't figure that out, then this probably isn't the right job.

This is not just a look at how technical I am. Job computers are incidental to the.

Maybe change after you got into the role. I'll let you go ahead, Lee. Yeah, I kind of touching on what Joel said a little bit, I think I didn't realize how motivated or unmotivated staff, uh, can be based on our interactions with them and how um, an unmotivated staff member can do very little and a very motivated staff member can do so much.

And so what really is about people? You know, we think about technology. It's, it's a one or a zero, right? It's either working or it's not. It's either moving forward or it's, or it's not. But that's not people. People move forward, three steps forward, two steps back, and they are, they're human beings. They're.

Deeply committed to, uh, getting this right. They wanna do the right thing. They wanna know they're doing the right thing. They want feedback around that. They deserve feedback around that. And I would say that's probably one of the most important things I do as CIO is identify that and do my very best to not just myself, but rally my leaders to give that kind of feedback to folks so that they know that they're doing great work.

So I think kind of encompassing some of what both Joel and, and Lee said, one of the early things that I didn't really realize that have really grown to appreciate. When I decided to take on the responsibility of being the CIOI became also a part of the senior executive team and our CEO at the time,

Who is, is not with the organization anymore, but our current CEO absolutely has the same philosophy. I remember him telling me and, and of, and all of us that we're in the senior executive team, you are a leader of this organization and a part of this senior team to set strategy and to set the path for the entirety of the organization.

And that comes before. Whatever you're the C of. So the CIO is sort of my second job. My first job is as a collaborator on, uh, a senior executive team to really make sure that whether we're talking about a. Something that has anything to do with technology or not. It may be significant HR decisions, directional changes that we're making in in benefits packages, in how we're addressing our most recent engagement survey.

Those are things that I bring. A leader role as a leader in the organization, totally irrespective of anything to do with technology. And that's my first job. And if we're doing that job well, then my second job is even easier, which is leading the teams within the technology division, which is absolutely about all the things that Joel and Lee mentioned, which is mostly people and process.

Stephanie hit it. Sorry, just quickly she hit the nail on the head on that one. I, I say it a little bit different over here, which is half of my job is to be CIO. The other half of my job is to solve my CEO's problems. And I didn't realize that out of the gate, but she's, she's spot on on this, that you are an executive in the organization and your job is to help the organization solve organization-wide issues.

I, I would imagine so. If I'm a physician listening to this, this idea of continuing to practice probably is, is, is top of mind. Joel, just outta curiosity, I said practicing telehealth. Stephanie, she isn't Joel are reporting. Yeah, so I am, so, I, I have a really great setup. I tra i, I split shifts with my former partners, and typically what I try to do is like 5:00 AM to 9:00 AM or 8:30 AM one day a week.

And so what that does for me is it gives me clinical FaceTime every week. But you know, the beauty of emergency medicine is once you're, once you're done, for the most part, you're done and you can walk away and have the rest of you know, your day. Now the problem is you have to get up at three in the morning and go drive in and, and, you know, now you've gotta take a shower and, and really, you know, post a shift, decontaminate yourself in a way that your family's comfortable with.

So that adds some layers. Uh, you know, with the pandemic, but you know, it, it almost because I'm not responsible for the department in the same way that I used to be. It, it's, it, it's almost fun. Again, it, it almost feels like, well, I, I knew there was a reason I got into this in the, in the first place. It is, it, it, it, if you're not doing it all the time, every day and deeply responsible for what happens.

Uh, for in the department as a whole? It is. I, I've actually found it kind of liberating and there's no question that if you make it, your, your little goal to find one or two things to fix in Epic or, you know, look at this micro, you know, this dictation microphone that's been, you know, cloth taped back together or, or stuff like that.

We. We decided to start double side printing discharge instructions because it, it bothered me one day looking at all this wasted paper and, you know, it's, it's, it's the little things that, that connect you back to the people that you're supposed to be helping in, in the organization who are working 12, you know, five, 12 hour shifts as, as a lot of our nurses do.

So I still do it. I, I will tell you. What I'm noticing as I get older is that it's actually a lot harder than, than I thought it would be. Not to stay current, but kind of. So it's not that you don't know who these people are anymore, these, these nurses that you've never met or these, you know, hospitalists that you don't know who they are, and you don't have that relationship where you can have a conversation about what you wanna do, but it might not be exactly what they wanna do.

Those relationships are are critical, but there'll be some drug where you don't know what what that is, and you've gotta figure out how to learn to keep learning in a way that isn't all consuming, and you've got to open your mind up to the fact that things are going to change. I remember a patient who I, I, it wasn't my patient, but I was there.

Who had pneumonia and somebody had put them on what is called BiPAP, which is this, it's a form of assisted breathing where you put this mask over the patient's face and it kind of blows air at them. It's like power steering for, for breathing. It's not. Nearly as invasive as putting them on a ventilator, but it's, it's kind of some breathing support.

The problem is BiPAP has a lot of downsides and in pneumonia patients, it turns out it's really not that helpful at all. We've come to learn, and I remember the first time I saw an intensivist come down and, and get been outta shape about seeing this and me thinking, I didn't know that. I didn't know you weren't supposed to put pneumonia patients on BiPAP or.

You know, I didn't realize we changed our antibiotic algorithm for, you know, this or that. You, that, that will happen to you more and more and you'll also get crushed with email and phone calls and text messages that you feel compelled to answer and you have to put it aside or you will, you, you will quickly lose control of your clinical space if, if it's a place like the emergency department.

Interesting. And Stephanie, I'll get to you in a minute because you, you chose a different path, Lee, you chose the same path in terms of continuing to practice in a scaled back fashion, upsides and downsides to that. Yeah, I was, I was really concerned about practicing infrequently and I was trying to figure out a, a mechanism within my construct to make that happen.

It just was really difficult to do it in the er. I thought about doing, you know, maybe just do upfront triage for a while or do the fast track, and eventually I decided to just do urgent care video visits on occasion. And that, you know, that by the nature of that work, it, there's a, there's a selection process where you're only getting people who really are appropriate for that kind of a visit to begin with.

And so the risk is already by, by the very nature of the scenario, much less. And I was concerned about, you know, scaling back my emergency medicine practice to the point where I wouldn't be fully capable. You know, I, my wife asked me a question at one point, she said, and as I was thinking through this, she said, if, if I was sick and I went in the er, would you want me to see you?

And I hadn't been practicing very much at that point. There'd been a few months that had gone by and I thought it's a good question to ask. So, um, I scaled back to telehealth and, you know, I figure in my current role doing telehealth actually makes sense. You know, I get to use the technology, I get to understand it.

It is, you know, maybe not bleeding edge, but it's, it's on the front edge of how we're advancing technology with healthcare. And it does allow me to, uh, have conversation with folks about. How the technology can impact the care that's delivered. So for me, it's kind of a nice balance. I also found myself this last summer in a strange scenario where I had to recert and, you know, I was scratching my head, do I, do I recert or do I not?

It's gonna be a lot of, you know, I'm gonna sit there and watch those videos. Right. With, with Rick Ada and Billy Mellon and just watch these things for hours and hours and hours and take a thousand questions and then finally sit down and, and do it. Do I do it or not? And ultimately it was nearly impossible for me to not do it.

I felt really compelled that it's, it's part of who I've become, and so I wanted to maintain it. So that's kind of where I landed. Stephanie, you chose a different path. Give us, give us an idea of, of how you came to that decision and the pluses and minuses. Yeah, I mean, this has definitely been probably the hardest part about the transition that I, that I made, and not really because I, I mean, I loved patient care.

And I, and I think I was good at it. My patients liked me. My, you know, I, it was, I think it was a good experience all around. I. Uh, but I don't, I don't wake up in the morning like missing that aspect. 'cause I feel like I'm having an impact on, on kind of a greater scale. And some of the things that on an individual patient basis, I might feel like I was slamming my head against a wall.

I can now, instead of slamming my head against a wall for 15 patients I can try and fix things so that nobody has to slam their head against the wall. So that part has been good. It's been more very deeply internal. Almost a feeling of beating myself up a bit around. I. All this, you know, all this time and energy and work that I did to get to where I was clinically, and then to quote, you know, potentially be viewed as leaving it behind.

And I was, again, I think my, my own worst critic as far as that was concerned. And again, it kind of just happened over time. And the further ti more time that went by, the more I was like, well, gosh, how am I gonna. Build that back in as a hospitalist, it's a little bit different. I mean, I can't, it is shift work, but you don't typically just show up for a day or a shift.

You need that continuity of two, three or four days at a time. I've got small kids and another full-time job, and so there was that question of collateral damage of like, well, I guess I, I could do a five days a, a month. You know, kind of rotation on top of all the other work that's gonna have to continue and sort of deciding that it wasn't worth that collateral damage, but having to get okay with it myself and not feel almost ashamed to admit I'm not practicing anymore.

Like I used to feel like I was apologizing, oh gosh, I'm really sorry. I don't practice anymore. And now I've gotten away from that and sort of saying. I don't, I don't practice anymore and I use my clinical knowledge all the time over the summer. And as things were happening with the pandemic, my team was the one who stood up.

Nurse triage, my team stood up the secondary escalations of, of the televisits. From that I was their medical director. I answered the escalated medical questions. I was doing the radio in new spots on, you know, sort of how we were managing this. Who should be tested, who shouldn't. And, and certainly did talk to and do some video visits with patients in very specific areas over time.

So it's not something that I think to Lee's point in, in the right situation I can't go back to, but it is never gonna look like it used to. And I think as physicians look at going into roles that take them away from clinical practice, it's really some deep introspection you need to do around how you want that to

To, to play out and what kind of balance you wanna have. I have physicians that work for me, some that do, you know, 20% clinical time and some that flip that and do 20% for me and 80% clinical time. So you can be a physician informaticist and have a role in it and making things better and and improving things, but be mostly a clinician.

Or you can go to the other extreme, which is where I'm at now, where you can do all of that. And to Joel's earlier point, you know, saying you have to be the no person. That's one of the things I coach my physicians that work for me on as they're evolving. Where they wanna go with this is, do you wanna be a yes person or a no person?

If you wanna be a yes person, the leadership roles are probably not the best for, for being the yes person all the time. A, a physician informaticist is a great yes person job because basically you go to your colleagues, you find the problems, and you figure out a way to yes, you figure out a way to make the problem better, and you get to say yes to people a lot.

The more responsibility you take on in the organization, the more likely it is. There are times that you're gonna have to say no. And so like the informaticists that work for me, they love that they get to say yes all the time. And if there's something that's leaning towards, no, they kick it up to me and they're like, Hey, we think this is a no situation.

Can you use your no skills ? And you know, and that's really a piece that you need to know about who you are and what you're wanting out of your career path because. Physicians are gonna, I think, be welcomed into all of these roles because of all the things that we've talked about. So then it's really knowing what do you want out of it and where do you wanna stop and when do you wanna keep building?

Yeah. I, I, I wanna close, we're, we're coming up on the end here. I wanna respect your time. I wanna close with giving the next generation a.

And I, you know, what, what would you, you know, what would you relate to them? What would you, if you were to rewind all those years, way back when, even maybe, maybe before you studied to be a doctor back in your undergraduate. What do you wish you had really focused on or maybe picked up in your, in your education years that would would've prepared you maybe a little bit, a little bit more for what you're doing?

Uh, let's make this brief. I'd like to hear from all three of you just in the last couple of minutes we have here. Lee. Lee, do you wanna go first? That's. Psychology . If I could pick one thing would be psychology. I think, you know, it's all about people at the end of the day, and it's all about working effectively with people, whether that's change management to Joel's earlier point, or whether it's about studying strategy and vision and motivating your team.

Whether it's removing hurdles or saying no, as Stephanie talked about, it's really, psychology is really a big piece of what we do. And so I think if you're asking me what would I do a little bit more of in preparation for this role in my younger years, it would've been to go a little bit deeper on psychology.

Fantastic. Uh, Joel? Well, leaving aside the, the alternate, you know, musical career that, that I could have had. You know, I think you've really gotta know yourself and you've gotta listen to your voice and ask yourself, do I like what I'm doing? Do I like the day-to-day of what I'm doing? And what do I notice around me about people that I admire who look like they're enjoying their day to day?

And does that fit with me? Part of the problem with becoming a doctor is that you're on this conveyor belt for, you know, a decade, and frankly a lot of it is hazing. So I don't really know that we need all the biochemistry and cell biology and all the, you know, the nonsense and the flashcards and the staying up until, you know, however, two in the morning to, to memorize all this stuff.

You know, your twenties will be gone with that. It's not that I would've done it differently, but you've gotta, I, I have plenty of colleagues who, who get to their fifties and they're like, do I have to keep doing this? Really? And they haven't developed the skill of looking around and, and sidestepping to something else.

Or they'll try to sidestep in a way that is just very restraining. To, you know, just telemedicine as opposed to, wait a second. There's all kinds of things I could do with this, with this career. If you told me two decades from now that I would be the CIO of an airline, or you know, a complicated. Logistics company.

I would love that because to me, that would just mean I, I keep growing and I keep changing. And so I, I think when you're early in your career, you've gotta water that plant really carefully. Fantastic. Stephanie, you get the last word? I think I, a lot of what's being highlighted here is, is keeping your mind open.

A physician path does not look like any one thing. It can look like so many different things, a clinician path in general. I, I think a clinical background is an amazing thing to bring into a whole bunch of different areas and, and I think, you know, I don't think any of the three of us, if you had asked our, your, you know, to speaking of 20 years in the future, 20 years ago, if you would've asked me if I'd be the CIO of a health system.

I've been like, no, I, you know, that's, I, I don't, I barely program my own, you know, computer at home. And so, so I think it's just keeping your mind open to paths that come in front of you. And then to Joel's point, understanding yourself and then to Lee's point, understanding the people around you. Fantastic.

Uh, you guys did not disappoint. This was fantastic. I.

12 years ago, I would've learned so much back then. So hopefully we produce something that people who are in school today and who are contemplating this role can, can really learn from. So thank you very much for your time and thanks again for Eli Tarlow's Serious Computer. Really appreciate the, the brainstorm on this idea and really bringing it together.

Thanks everybody. Great to meet guys. 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. I know if I were ACIO today, I would have every one of my team members listening to this show.

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