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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, 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 has been sponsored by Sirius Healthcare, and now that we're exiting the series, Sirius has stepped up to be a weekly sponsor of the show through the end of the year.

Thanks for sharing it with your peers. It is, uh, greatly appreciated. So to make it easier for you to share it with your peers, we are launching a thing called Clip Notes this Friday. What is Clip CliffNotes and why another subscription? Well, several CIOs have said to me that they don't have time to consume every podcast.

That we record, but they love the content. They were looking for a way to skimm the podcast, identify the content that was relevant for their team, and forward it along to those team members. Uh, I heard the word Skimm and I immediately harkened back to high school. And, uh, my best friend in high school was a thing called CliffNotes, uh, CliffNotes or SparkNotes, which summarize whole books so I didn't have to read them.

And, uh, I could still get the key points from the book and pass the test. And that's what we're gonna be doing with clip notes. When you subscribe, you'll get, you're gonna get an email for each show that we release moving forward, uh, that has a one paragraph summary bullet points with timestamps of the key topics and one to four clips from the show in your inbox within 24 hours of the show being released.

You know, this represents a fair amount of work on our end, so please send me an email, let me know if we're hitting the mark. . But what we're trying to do is we're trying to give you a way to, to skimm the show very quickly. Identify the key points, see if there's relevant topics for you or your team. . That you wanna share.

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Uh, special thanks to our sponsors, VMware Starbridge Advisors, Galen Healthcare Health lyrics, Sirius Healthcare and Pro Talent Advisors, whose investment in the show has given us the ability to, to, to really hire additional staff and provide these great services. Okay. To the show, Aruba asked me to prepare a talk for their Atmosphere Digital Conference on the state of healthcare, and you can view this talk and others by signing up and attending their conference.

But Aruba also gave me permission to share this talk with our community through the podcast channel. So here it is. I'm so excited to have this opportunity to present at such a great event. I get to speak with and interview so many amazingly brilliant people in the work that I do, but it holds absolutely no sway with my children.

They pretty much know the truth, that I'm a nerd and I hang out with healthcare nerds and I have presented no evidence to refute this assertion until now. I'm presenting at the Atmosphere Digital Platform Conference, and I'm sharing the virtual stage with James Corden, who is one of my kids' favorite personalities.

Why you might ask, because they are Broadway music nerds, which I guess means the apple doesn't fall far from the tree. Here's what we're gonna do over the next 25 minutes, I'm gonna give you a lay of the land on healthcare in general. Healthcare, healthcare it more specifically, and then I'm gonna branch off into the significant ramifications of the events of the last couple of months on the network security and information sharing.

Are you ready? Here we go. First, who am I and why am I the one to talk about healthcare? My name is Bill Russell. I'm a former CIO for a 16 hospital system in Southern California with about $7 billion in revenue. That's how we talk. We used to say number of beds, but that didn't translate in conversations with our friends, so we switched it up a little bit.

So I'm a former CIO for St. Joseph Health, a 16 hospital system in Southern California with $7 billion in revenue. Why have a former CIO speak to you about the current state of healthcare? I'm glad you asked. I now do a little bit of consulting with healthcare organizations. But the most fun I have is that I started a podcast where I interview healthcare executives around the use of technology within their organizations and the industry.

This week in Health, it started a little over two and a half years ago, and we have done over 250 episodes. The first episode was downloaded about 28 times, and I wasn't sure I was going to continue past that first week. We now average about 700 downloads every single day. But the most relevant stat to this discussion is that we have produced over 80 shows since early March, and we started producing those shows to capture and share the best practices of the industry in health it.

Who have we talked to? We talked to the CIOs and CMIOs of Michigan Medicine, atrium Health, Mayo Clinic, three Baptist Health Systems, Kentucky, Tennessee, and Florida. St. Luke's in Pennsylvania, envision Healthcare Methodist Providence, Mount Sinai, city of Hope Hospital for special surgery in New York City.

Cedar-Sinai in La Vanderbilt, the Ohio State University University Hospitals in Cleveland, NYU Langone, Boston Children's. We also talk to CTOs at Ochsner and Stanford Children's. We talked to CSOs at Cleveland Clinic, Intermountain Health, Indiana University Health, and several others. You get the picture.

Our field reports provided insight and visibility into what the industry was doing during these extraordinary times. Let's start by taking a look at the events of the last couple of months through a technology lens. We've been talking about digital transformation in healthcare for over a decade, but the progress really has been slow.

Can it enable healthcare to do more with less? Healthcare providers run at about three to 5% operating margin in a good year and negative margins in a bad year. There is always pressure on their margin because of the cost of healthcare and the cost of healthcare is generally considered to be too high, not generally.

It's considered to be too high, and really at this point it's running at an unsustainable percentage of the GDP for the US approaching nearly 20%. We're hopeful that technology provides part of the answer. Other questions we were asking, can it get us closer to those we serve? Can we get more personal and provide more directed care when where it is needed and when it is needed?

Can it reach beyond the hospital walls in the community? We see the average person in the community less than one time per year. It's hard to impact the health of a community if we aren't in relationship with them on an ongoing basis. How will healthcare plug in is a nod to the growing IoT market in healthcare and the expected proliferation of APIs.

Maybe that one was a little too forward-leaning, but it isn't anymore. As the 21st Century Cures Act is moving to open up healthcare data and is set to make a major impact in the next year, why the history lesson? Because we made two years of progress over the last 10 years in healthcare, but we made five years of progress over the last three months.

we've accelerated DI Digital transformation at a level that no one really anticipated, and it was due to the crisis. Why talk about digital transformation at all? Because we believe that technology holds the key to reducing costs, increasing access, improving quality and outcomes, and fundamentally changing the experience of the patient and provider in the healthcare transaction.

This is known as the quadruple aim. , this is the promise of technology in healthcare. Why has progress been slow? Because the, an answer isn't always in the technology. In fact, it rarely is. Financial alignment, culture and regulatory burden are barriers that stand in the way. So we meandered, meandered in this, in this journey for a little over a decade because reimbursement was low and regulations were high, and healthcare had no incentive to change.

Then covid hit. safety became the priority in, in healthcare during the pandemic. Right. Well, that makes perfect sense. Offices closed, EDS changed their policies. Chronic patients still needed to be cared for. Safety required us to do this from a distance. CMS, the government payer of Medicare claims opened up 80 plus codes on which healthcare providers could now bill Telehealth at almost the same rates they would in office visit.

A physical office visit. Commercial payers followed suit. The federal government reduced security restrictions for telehealth, making it easier to implement solutions quickly. Early on in the process, I did an episode that we entitled MacGyvering Telehealth, A nod to the television show from a long time ago where MacGyver would take a rubber band and make like a, a missile or something.

It was a a really fun show back then, but that's what we were doing in healthcare. We used FaceTime, zoom, WebEx, anything, and everything was being thrown at the problem. Finally, the government lessened the regulatory burns, allowing the physicians to practice telehealth across state lines and reduce the likelihood of a post covid audit.

It, the perfect storm had hit, it, paid to do telehealth, and it was a lot easier to do it without getting in trouble. Visits went up a hundred fold for all healthcare providers. Um, but recently UCLA shared with me on the show that their growth in visits went from 400 visits a year ago at the same time, to over 80,000 in the same month.

Don't forget that I mentioned the chronic patients. These are non covid patients that were already battling other conditions. These people still required care and follow up. Telehealth was a part of this, but so were a whole host of remote patient monitoring devices. Home-based care is one of the most exciting frontiers in healthcare and one that just had a massive experiment in scaling.

It. As with any experiment, we will take the new learnings away from this, but we will also be what we're gonna be doing. What we did do is we introduced a set of patients to a, to a new set of behaviors and options that they didn't even know were available to them before. So drive home the point that I'm not the only one who who thinks the home, that home-based care is the future.

Look at this headline from last year. Best Buy Healthcare Strategy, 5 million Seniors in the next five years. Did you know that Best Buy had a healthcare strategy? Their strategy is to stand up the home to allow for aging in place. They will provide the technology and utilize their Geek Squad to implement the technology in the home.

Our homes are the next frontier in healthcare delivery, staying with technology. There was a second major move in healthcare that was work from home. This wasn't unique to healthcare, but it was foreign into healthcare. We had mobile workers, but nothing to this scale. Policies were adapted and adopted overnight.

Technology was scaled up and new habits were formed, and possibilities were explored. Meetings went virtual. Some CIOs cite that, that this was progress in productivity, eliminating the transportation between locations for meetings. They also cited that meetings went from being a natural one hour to 30 minutes or even 15 minutes.

you know, being ACIO in Southern California with many buildings, I can relate to this, sometimes my drive between buildings would be an hour, uh, just because of the nature of Southern California traffic. You know, this created an interesting conversation around productivity. Executives started to ask if we were taking a hit in productivity, to which they found out that they didn't really measure productivity all that well prior to covid.

Anecdotally, they found that they had shorter crisper meetings on video than they did in person. teams were creative. They stood up impromptu water coolers to talk about the family, uh, tips for working from home and even happy hours together to maintain the relationships they missed in the office. The work of healthcare, it was amazing.

Overnight they stood up these, these new capabilities, the teams had a new level of focus and roadblocks have been eliminated. , the stories I heard were exceptional and in some cases fun. I heard of health systems that that went out to the stores and purchased every tablet they could find from the local electronic store.

They then put the tablets into the rooms to reduce the touch points with covid positive patients. The side effect was that they were able to address the isolation problem that had arisen that because we were not allowing families into the, into the hospitals . Because of safety, these patients were experiencing, uh, loneliness and isolation, and we were able to use those same iPads and those same mobile devices to bring the families into the room to address that isolation.

So let's talk about these extraordinary times and the current state of healthcare, healthcare stepped into a public health void. as an industry, we stopped elective procedures, which has a wrong connotation really outside the industry. The better way to view this is required non-urgent procedures. I can guarantee you if you need knee, knee replacement, uh, it is considered an elective surgery.

But if you're the one who needs that knee replacement, living with the pain, you may take exception to the term elective surgery. , we diverted people from the emergency department by standing up remote testing facilities and virtual care options, and we stopped most office visits with guidance around social distancing.

If you're wondering, this is the equivalent of closing your primary funnel of new business and stopping the sale of your most profitable products, healthcare did all this before we even knew there was gonna be money coming from the government. Healthcare stepped up and stepped into the public health void.

We then started to incur costs. Most, if not all, administrative staff moved to work from home. We scaled telehealth in a major way. PPE, uh, protective personal equipment was constrained and the cost went up significantly, and we stood up new venues for care overnight. This created the second crisis for healthcare, the financial crisis.

Healthcare is in the process of handling the crisis of the pandemic while just now trying to figure out the depth. Of the financial impact of all these efforts, and it was extremely impactful. We have since seen, uh, millions of healthcare workers furloughed or salaries reduced and cut. This will impact health systems unevenly to be sure.

Some health systems have large cash reserves and significant endowments. They will be impacted, but they're, they're gonna do okay. Smaller hospitals though, which often serve rural and underserved populations, may need help to weather this storm and some may not make it. Many I've spoken with expect that this will be a pivotal event in healthcare's history, and uh, it may never look the same.

And some think that may be a good thing. There are some silver linings out of this. We, we created some new behaviors, we learned some things, and we're gonna take those things forward. Let's talk about some of that. I wanna focus in now on the three areas we have seen the most dramatic change, and that is connectivity, security, and information.

Let's start with the network. The center of gravity of the network changed dramatically in healthcare during the crisis. It used to be that 90, 95% of all the traffic related to healthcare originated from within the four walls of the health system. , they may have been on wired or wireless networks, but the traffic request originated from within the four walls on our networks.

Over a three week period, we moved nonclinical administrative staff to their homes. We asked patients to connect with us remotely and we, we were asked to stand up these remote facilities for testing and treatment. This represented a major and massive experiment for healthcare. What did we learn? We learned that our carriers, in most cases were wonderful partners willing to stand up additional bandwidth in a time of crisis, but we also learned that bandwidth wasn't all we needed.

the traffic flow FU fundamentally shifted with the center of gravity, and we found that our hub and spoke framework was not the most effective network design. Some workloads buckled under the architecture hardware-based solutions were less flexible and revealed the need for for software defiance Solutions with dynamic routing software is always, always more flexible and agile than hardware-based solutions.

What else did we learn? We learned that 15% of our telehealth calls were not successful. This wasn't because of the health systems network, but because the limitations that we have in education and access. We had many telehealth sessions that experienced less than ideal performance because people just.

Didn't understand the concept of the video visit. Um, we hadn't educated them. They didn't really comprehend what was going on. Um, you know, I heard some interesting stories. Stories ranged from people calling, uh, calling into their telehealth visit while on a hike in a remote trail somewhere, expecting to be able to complete the consult in, in, in which they had very little connectivity on their cell phone.

Right, so that was one side of it. The other side was people who just had no connectivity at all because the patient doesn't have access to broadband. Telehealth has enormous potential to bring a higher level of care to remote parts of the country, but it's gonna require a concerted effort by the federal government to improve broadband access, a point that they readily conceive.

The FCC made over $200 million in grants available to health systems providing telehealth during c Ovid 19. The source of the funds being the FCC suggests that access to broadband is understood to be a health related issue. Okay, on my Tuesday News State show, I review review news stories, and at the end of each story, I end with, so what?

So what? Who cares? Why does this even matter? And I'm gonna end each of these sections with a, so what? The network has fundamentally changed and been pushed way beyond the boundaries of the traditional healthcare network. So what? It has significant security ramifications for sure, but I'm gonna get into that in a moment.

The main thing we learned is that hardware is not agile. We need networks that allow for all workloads to be remote, and we need intelligent routing based on ai and more specifically machine learning. We need networks that can adapt. At a moment's notice to the changes in the world that deliver the same performance that we experience in the office, we need to support yet unimagined configurations and use cases.

In other words, we need to be able to support the unknown by focusing on what already is known. What do we know? We know we have more complex and bandwidth intensive workloads, and an increase in mobile and remote work, which means we need more intelligence at the edge. Okay, let's talk about security. The number one attack during coronavirus during the pandemic was phishing.

Nothing new there. But what is new is that all the attacks coalesced around a single topic, c Ovid, 19. The reason is obvious, it was a critical time with an urgent need for the sharing of information around a single topic. Nothing had changed. The actors exploits, lures, and payloads were not new. I had Ryan caller, EVP of Cybersecurity strategy at Proofpoint on the show to discuss the security landscape during c Ovid 19, and he explained how Coronavirus is perhaps the most clickable lore that we have ever seen.

I don't think, and this was a quote from him, I don't think we can point to a single event in history in the history of cybersecurity going back 20 years. Where we can remember every single type of actor jumping on one lore bandwagon at exactly the same point, which is what we have seen, basically seen since January.

The actors are who you think they are, nation states, smaller targeted regional actors, and also scaled up cyber crime actors. He, he went on to talk about that there's hundreds of thousands and potentially millions of payloads, 70% of which are malware. Malicious software designed to compromise some aspect of your computer, remote access, Trojans key loggers, some downloaded functionality as well, meaning a piece of malware that can be turned into something else later when it's needed.

And often that is, that's sold on the open market. We have access to this computer and we can translate it into something else later. . You know, we didn't see a host of new attacks during covid because the old attacks were working just fine. Thank you very much. No need to go through the process of inventing something new or finding some exploit when end users will just click on an email and give, give someone access.

Send out in the email that looks like it's from the CDC or the, or. The World Health Organization could be from the State Health Authority, or, or, or heck, even the IRS and the click rates were extremely high. You know, why talk about security at this point? How did it really change? All these things would've been true in an office environment for the most part.

A couple of things happened. People were out of their normal routines. You may have walked down the hall to verify a wire transfer normally, but you weren't in the office to do that. But let's, let's actually focus in on technical controls. I had CIOs tell me that computers were significantly constrained at the very time they were sending people, uh, to their homes to work from home.

This meant that they were asking people to work on non-company issued computers to access the network and company resources. Can you think of anything that might go wrong in this scenario? I mean, let's think about this. If your CFO is working on the same computer that their kid was playing Fortnite on yesterday or worse.

Uh, going to a site that wasn't Fortnite and downloading hints and tips on how to win in Fortnite, which is probably a more vulnerable activity, you know, key logging enabled on that computer. Enter the CFO of the company with instructions on how to get on the company's network from home. What about the home wifi network that hasn't been patched since the day you unboxed the router and set up the home network?

Okay, but before you start worrying only about the, the home or too much about the home, don't forget the holes in the VDI environments, the vulnerable VPNs, other devices like application controllers and the like, that can provide access to the whole shoot match in one fell swoop. So what I love this quote from, from, uh, Ryan on the show and what he said is that cybercrime is now a top 10 global economy, no matter how you measure it.

It. We need an agile network that allows us to be responsive to the changing businesses, as we described in the last section, but as we move the devices out of the office and into the wild, we need to maintain our security controls and become even more vigilant to verify the identity of those devices, the person behind the computer, and monitor the activities that would constitute normal behavior for that person and that device.

I dubbed the last section, uh, information because I wanna talk about two aspects of information that I feel will be forever impacted by CVID 19. The first is information sharing, and the second is the proliferation and acceptance of remote devices that generate medical data. C Ovid 19 revealed a significant hole in our country's public health framework.

I'm gonna focus in on information sharing. I did an interview with the people who put together a thing called the Arizona Surge Line, which aggregated information from hospitals across the state of Arizona to provide a realtime look at bed capacity and critical equipment like ventilators. The State of Oregon through the Oregon Health Authority did something similar with its command center at the Oregon Health and Science University.

If you're like me, you're thinking, fantastic. That's exactly what needs to happen, right? The ability to see these critical items in real time across the state is extremely important during a pandemic, and it was set up in some cases in less than three weeks. After you let that sink in for a couple of seconds, you might have the same thought I have, which is, Hey, why hasn't this been done before now?

That's right. A Republican Congress passed this bill and sent it to a Democrat president where it was signed into law. Wow. That's, that's not something you hear every day. What kind of law could be so obvious and have no downsides for either party to support it? Well, the answer to that is it the 21st Century Cures Act provides for the free flow of health information across the Nation's Health Network to support the finding of cures.

I'm gonna spare you the, the specifics around this, about precision medicine, information blocking and health information exchanges. But suffice it to say that this is the biggest regulatory move that healthcare has seen in over a decade. Healthcare systems are required to share healthcare information or be found in violation of the CARES Act.

There's huge fines associated if they don't feel the request for information is valid, it is incumbent upon them. To request an exception to the rule in healthcare circles, this is a very big topic. It is believed that this will free the data and that data liquidity will lead to a more transparent and useful healthcare system that has the patient at the center rather than the healthcare system or even the the electronic health record.

Every patient has a right to their healthcare record, all of it. In electronic form when they request it. Let me come back to that. Earlier I spoke about chronic patients. This is a vulnerable population. Uh, and we immediately told this population not to come to the hospitals if it could be avoided, but we still need to find a way to check in on these patients.

We launched pilots on all sorts of devices to collect vitals and monitor the status of this important group of people. All of these devices fall into the category that we technologists like to call IOT. The internet of things is real in healthcare. We are now looking at rooms that could have upwards of a hundred devices connected to the network, pulsing out information on a regular basis.

This represents a significant amount of density in the hospital and that density . Is now moving to the home. Home Hospital rooms are a significant part of the conversation. Now in healthcare, we have e ICUs where clinicians come into a room that looks like a call center or a data center, and they monitor hundreds of ICU beds across the city, or a region one clinician watching the vitals and checking in on patients remotely.

The question we are asking now is, can we provide that same level of care with a group of sensors, . That is remotely monitored by a clinician out of the home. The so what I think is pretty obvious on this one, the free flow of information in healthcare is one of the last barriers to drop before we see a massive digital boom in healthcare.

The 21st Century Cures Act makes this a reality. Remote sensors in the room and now into the home will provide a level of care that before now was only available. At roughly $8,000 a night in a specialized room. Since I'm talking to technologists, I wanna close with this. This will only be possible if we provide the agility, security, and the framework for processing and moving and sharing information at the edge.

I want to thank Aruba for inviting me to share at this great event, and I want to thank you for spending the time with me. I wanna thank you for, uh, listening to this, to this show. Clearly, I was really focused in, it's an Aruba conference. It's about digital infrastructure and those kind of things. I was focused in on those types of topics for this show.

If you have any questions about this, feel free to shoot me a note, bill at this weekend, health it.com. More than happy to discuss any, any aspect of it. So . Special thanks to our sponsors once again, 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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Please check back off, and we're gonna continue to drop shows every Tuesday, Wednesday and Friday. Thanks for listening. That's all for now.