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 Welcome to this Week in Health, it influence where we discuss the influence of technology on health with the people who are making it happen. My name is Bill Russell, recovering healthcare, CIO, and creator of this week in Health. it a set of podcasts and videos dedicated to developing the next generation of health IT leaders.

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If you're interested in either of those services, check 'em out on the website. Today we're starting another of our interviews from the Health and Analytics Summit in Salt Lake City, put on by Health Catalyst. If you're trying to apply data as a transformative part of your healthcare strategy, this is a fantastic event.

So I caught up with John Halamka, who's been on the show a couple times. He was giving the keynote closing address at the conference, and I thought I would ask him, since he's been traveling the world, talking to so many people about innovation and where healthcare's going, I thought I'd ask him to take us a little bit on that journey and, uh, to share with us what he's learning as he's traveling the world.

Have a listen. Hope you enjoy. All right, another session from the, uh, health Analytics Summit for, uh, sponsored by Health Catalyst. And we have Dr. John Halaka here who is going to speak this afternoon. Welcome to the show, John. Well, thanks so much, uh, multiple guests on the show. I appreciate you, uh, coming back on.

So what are you gonna talk about this afternoon? I travel 400,000 miles a year these days, , and I go from country to country figuring out what works and what doesn't work in digital health. Big data analytics, cloud APIs. That is, is that an exaggeration or is it No, it's unfortunately reality. Wow. So, right.

I left Boston yesterday morning, came to Salt Lake going from Salt Lake to Tel Aviv. Tel Aviv to Shanghai. Yeah. So I tell people, it's like, well, I'm going to San Francisco by flying East , . Got it. Wow. That's, that's, that's amazing. So, I'm sorry, so what are you gonna talk about this afternoon? Right. And so I'll look at all of the countries I'm visiting and what are they doing in digital health and why?

And so you can imagine every country has an urgency. Uh, so in the case of a place like India, India has 1.3 billion people, 600,000 doctors. It's hard to get to the right doctor or the right specialist at the right time. And the tools that we have to do that aren't so great. But pretty much every family in India has a four G Android phone.

So you start to ask the question, aha, could you create a community health worker in each village? Give them a hundred dollars of Internet of Things, devices? When a person is sick, they go to see the community health worker, the internet of things, devices, gathered, telemetry. You then do a telemedicine session from a phone to the appropriate specialist and deliver the right care in the local community.

I mean, is this hypothetical or, oh, this is what's going on. This is what's happening called present a use case where I was is in Northern India. Near, uh, it's on the ganji, it's near Nepal, uh, working on a tb. Clinic for the Gates Foundation and we had a, a woman who had abdominal pain postpartum, and it turned out she had abdominal tuberculosis.

Now in the United States, I've never seen abdominal tuberculosis. But in India it's actually kind of common. And so it says to us, we really need the tools that will personalize our care. Where are you? When are you, what are your symptoms and what are the likely things it could be? Wow, how much of this stuff is gonna be applicable across

Geographic boundaries. I mean, 'cause India is very distinct from China, is very distinct from Singapore. I mean, they're, it's, they're, they all have very different, um, very different challenges, very different government structures and incentives and, and whatnot. Uh, it is digital health gonna be one of those things that sort goes across and we're gonna be able to move the things around the world.

So as you say, every country has different regulatory framework. But every country still has the problem of increasing healthcare costs in an aging society and not enough clinicians to go around. You have to do something right and digital health seems like the best bet for most countries, and therefore, what we see in Sub-Saharan Africa or India or China is very likely going to be a learning opportunity for the us.

What are you seeing in, uh, have you been to China? Oh, uh, so I am heading to China, uh, tomorrow. , well, I have three days actually, but, um, and so what are some of the things they're dealing with in China? Higher corporation, which makes 10% of all the appliances in the world, uh, they make, if you had a dorm, refrigerator, they made it,

Got it. Ask the question, could we put health monitoring devices in your appliances? Right. I mean, it's sort of why not you go to the kitchen when you're sick and do your telemedicine consultation from the kitchen? You know? And so we're exploring that. And China is very geographically diverse. And if you look at an academic medical center in Shanghai, fabulous care, if you look at Tibet, harder to access.

So how do you bridge that gap? So it's, it's very applicable to rural America. Yeah, that's, that's what I was just wondering. I mean, when you look at China, it's huge. You're right. Just geographically, but uh, advanced in some ways. So you would think that, do they have four G from one end to the other? Not really.

Well, that's the fascinating thing about Sub-Saharan Africa and China. They didn't put in landlines, they went right to four G. And so I, I joke with folks I live outside of Boston that, you know, whether you use at and t, Verizon or other carrier, you'll get three bars, you know, in a suburb of Boston. I'll be with a farmer in rural China with five bars of four G.

It's ubiquitous in these countries because it's the only way to communicate. 'cause they didn't start with Alexander Graham Bell. Exactly. Um, yeah, it's interesting that you can, uh, that you can jump technologies like that, like countries just can make a leap over what was right. See, I skipped client server entirely.

So sometimes you just get lucky. Yes. uh, Africa, I think we've talked about, uh, before you've, you've done some work with the Gates Foundation down there, have things progress. You, you were talking about like on a Nokia phone, not even a smartphone, right. Feature phone. And the idea there, this is an interesting architecture.

You use biometrics to identify and track the patient because every society has this question of how do you identify the patient. Right. And some like the Nordics will give you a healthcare identifier at birth and it tracks all your data for your life. But a lot of other countries have named gender date of birth in the US They say, oh, social security number, that's useful.

No, not really. 'cause lots of folks don't have one. You can't really use it for health. So this idea of using biometrics to track your data has worked really well in the right to care clinics and then delivering to the patient insights about their data on a feature phone. National patient id. Where do you, where, where are you on that conversation?

Well, I would love a national patient id, but politically, this has always been a hot potato. So how about this? At very least, we need a nationwide patient matching strategy. Sure. And the Pew Charitable Trust convened a hundred folks and just published a report on what might that look like if we all just agree.

We're gonna use a combination of demographics and healthcare demographics outside of healthcare. Maybe it's your car registration, maybe it's your property tax bill. Biometrics, right? Combinations of things that is going to get us to at least the high nineties in positive predictive value for matching.

That's until we have the political will, that's best. We can probably do so. You know, we're talking about digital health, we could go into policy very easily, um, which is an interesting slope to go down. But the, what, what would accelerate or what is holding back digital health? Uh, when you talk to, you're now the chief Innovation officer and, uh, so you're, you're talking to Silicon Valley while you're talking to the Silicon Valley around the world, right?

Sure. Um. You know, what would accelerate it? What? What's holding them back from really making advancements today? So, as you suggest, there's a lot of policy issues. So suppose I wanna send your data from New Hampshire to Massachusetts. Common thing to do, right? People live on either side of the border, you would think.

Totally different consent models, totally different privacy regulations. So if I live in Nashua and I go to your health system, right? I. It's actually hard, really. Right, because you'd think in the live free or die state that regulations would be few, but it actually . Because government is not considered a trusted aggregator of data.

You know, it's in effect hard to aggregate data in New Hampshire and then send it across the border. And, and so we have 50 different sets of privacy regulations across this country and it would be wonderful if we could come up with a consent that everyone could agree upon and a set of rules of the road data use agreements nationally so we can exchange data more fluidly.

So, um. Where's that gonna come from? You know, we see, uh, uh, U-S-C-D-I, we see a Sequoia project, uh, part of, uh, TEF fca. Um. Yeah. I, I, is, is that the genesis of something or, and it might come from government, but certainly what's happened in Massachusetts is we've decided to handle it at a state level so that we can So, so that you can get something done, right.

So that we can deal with our urgencies now . Yeah. Because Tekas still a little ways away, percolating along. And it may very well be that industry will solve this. So as you say, look at care quality. Look at data use agreements, that health information exchange is used, and maybe private industry will get this done before we see government do it.

So you have a, you have a strong, uh, data sharing, uh, set of agreements across Massachusetts, right? New York has something similar, pretty strong across New York. Um, but between Massachusetts and New York, does that exist? And the answer is not exactly right, which is if you . Think about what Epic did with Care Everywhere, right?

They basically said, if you're an Epic user, here's a data use agreement you agree to, and we'll exchange across state borders, and that's all. Okay? And so things like care equality, data use agreements and care everywhere, data use agreements do go across borders, but there isn't a government entity at the moment.

That's giving us the guideline, the framework to do it. So is that the benefit of being an Epic shop is that you can share data technically across the entire country, you know, certainly care everywhere with, with another Epic shop. Yeah. Right. So Care Everywhere is a benefit, but also you'll have to look at the Commonwealth Alliance, right?

Care Equality. And so I think at this point though, care Everywhere was an early mover. The idea of being able to exchange data from Epic to Cerner and Cerner to Epic. Is supported by both organizations, uh, using the Commonwealth Alliance framework. So that's, it's happening, as I say, but that's a private sector initiated initiative.

Well, that's the thing I hear from, uh, I, and I think, I think this is exactly what you're saying. I hear, uh, access to data, uh, as one of the things that slows down. Um, but the other thing I hear is, and this . Might come off the wrong way to my audience, but it's, it's difficult to work with health systems.

It's difficult to work with health IT shops. Um, they're overburdened with, you know, you have to take care of the EHR. We're now at quarterly updates and with, with Epic, I, I'm talking like epic's the only thing, and it's not, I mean, but there's, uh, but you're, you're burdened with that, your burden with, uh, strategic your burden with cost reductions, um, with all those things.

And then I hear . Uh, you know, I have the best thing since sliced bread and I can't get the CIO to listen to me. Right? And I wanna say, do you, you want to know the 15 things that are in front, or 20 things that are in front of you? Um, 'cause people will ask me all the time, how do I get in front of the CIO?

Right? Um. How do we, how do we do that? How do we start to, uh, reduce the burden that's on the IT organization so that they can focus on what's next instead of taking care of what's before? Sure. So my view on this, and I'm starting to see it around the world, is that the IT shop will procure the platform and then individual say apps will provide functions and they connect to the platform.

So in effect, the EHR ceases to be the center of the universe. . Um, and this becomes much more agile because you can then say, oh, well here's an app that does something cool and I just want to connect it to the platform. And is a relatively straightforward action that doesn't revolve around IT governance to make such a connection.

And so I think the future of it in this country is instead of provisioning, will procure. And that means cloud. Yeah. And then so you're, you're not doing the updates. You're not doing Exactly. Um, you wrote an EHR. That's true. A who? R or just portions. Yeah. No, it's the holy EHR . Um, so you're one of the few people that, that we can have this conversation for.

What, what's the future of that? Will that start to become microservices and those kind of things? Well, and that's exactly right. So where is 27 petabytes of patient identified data for Beth Israel Deaconess stored today. Amazon, right? Right. So we moved all the data into a secure container under a business associate agreement with appropriate security and privacy controls to Amazon.

And why is that interesting? So now if you want to connect an app or connect a cloud service to Amazon, it's an Amazon to Amazon connection, right? Not so hard . So that's no question. You know, pick a platform. Whether it's Amazon or Google or Microsoft Azure, that's the direction. But that becomes, um, you know, I'm trying to phrase my question, uh, because you just went through the time honored tradition of a merger and acquisition.

That's true. So it's not just your EMR anymore, it's your EMR and probably two or three others. Right. Um, so you had that pristine data set that you had a data model that . Was very well known and but now you have different data models is what, what has that journey been like to try to bring that data into that set?

Sure. So the Accountable Care Organization, which is responsible for risk and value-based purchasing contracts for Massachusetts, says, doctor, we are happy to sign an ACO contract with you. Here are the minimal data set requirements for what you must submit from your EHR at every encounter. So you have a data model, right?

And so there is this mandate, and we just so happen at every encounter, inpatient and outpatient and e ed send a standardized data set to a central repository where it's normalized, curated, and then used for analytics. Fascinating. Uh, Dr. Perowitz last night said, if you had to do it over again, you know, mu to do over again, and I'm gonna ask you that question, but, um, you know, what would you do?

And, and Dr. Berkowitz, uh, with MD Live said, uh. He goes, instead of mandating, uh, EHR usage, I'd start with mandating a data model, and then I'd, you know, start with the rest of it. Um, I thought that, you know, and that got the murmur in the crowd as, as you think it would. Um, and uh, and it's interesting because we sort of go, you know, we talked to, uh, Dale and it talked about late Steve binding and all the things we have to do because we don't have a national data model.

Right. If you had to do it over again, I mean, does that, how would you, . Maybe re rethink how we went into meaningful use, right? So meaningful use, in my view, was too prescriptive, right? Instead of exactly as you say, focusing on an outcome. This is the data we want to gather and exchange, and we are going to incent you to exchange that data.

We said, oh, here's how you have to use the EHR , and the analogy I might make is if the outcome I want is for you to play music, should I really tell you you have to use a CD player? , right? Just as long as the music plays. I'm good. . So how did we get there? Yeah, I mean, well first of all, people have to remember context.

And the context was right. Healthcare was mostly paper. Um, . As, uh, as I'm sure you'll point out or many people point out, we're still the, the leading driver of fax sales in the, in the world is still healthcare. Um, so even though we've digitized a lot, it, there's still work to do. Um, but that's the context.

I mean, it was a paper-based, driven, and so I, I would assume I wasn't in the room. Um, but I would assume at that time people were looking at it going, look . , you have to start by digitizing, right? You need to put tools in place, and if we just say you need a data model, people might say, okay, we're gonna adhere to that data model on a piece of paper.

Yeah. Is it? Yeah. No, but I mean, why did it happen as it did? I guess the first reason is it was a stimulus program, so, right, that's That's right. So you needed $35 billion or so. Spent quickly. You couldn't just say, oh, we're gonna have a luxury of time and it'll be a 10 year project. No, it had to be spent quickly so that maybe we moved too much too fast.

'cause it was a stimulus program. And then the second is there were so many stakeholders who in a way, politicized meaningful use. Right. It became the way to get what you wanted. And so if you're a government agency and you say, oh, I need this data here. Let me get it into meaningful use . Yep. Uh, I'm gonna come back to our, uh, so come back to digital and to close it out and say, um, you know, we're seeing the proliferation of these titles and now we've talked about titles before.

Um, and the titles are just, uh, a, uh, manifestation of healthcare organizations are trying to become digital. Mm-Hmm. . What's the best way? Uh, you know, we now have Chief digital officer What? , you know, a chief, I, I, I wonder how far this is gonna go. Are we're gonna have a chief digital marketing officer and a chief digital right.

Financial officer and whatever. Are we, are we gonna finally step back and start having, figuring out how to retrain our staff to think in terms of a digital world and how it functions each one of those areas? Right. And as you say, this is an evolution of culture. So do you do e-commerce? No. You do commerce.

Commerce, right? . But when Amazon first started, it was like, oh look, this cool new thing is E-Commerce . And so instead of saying, oh, I do digital health, I just do health, right? So it'll become the fabric of how organizations run and deliver services. And is that gonna, I mean, how are we gonna retrain, you know, how do you retrain ACFO to think about it?

There was a great story somebody was sharing that their, their legal team. , I think it was, uh, uh, it was, it was a pharma company. It was dealing with Google, and they refused to do any agreements with Google. Hmm. And, uh, they, they got into conversations and they finally got the two groups together. And, uh, you just hear the, uh, the lack of understanding of what digital meant when one of the lawyers said, um, so every person in the United States has their own IP address.

Oh, now we, we giggle at that, right? I mean that's, that's a lawyer trying to sort of sound like they know what they're doing, right? 'cause they can say IP address, but that's the level of understanding. No wonder they're not gonna do a deal with Google. 'cause they, you know, so we have to retrain our lawyers, right?

We have to retrain our, uh, financial officers. We have to treat, uh, and whose job is that to ? I mean, how do you, how do you do that across an entire organization? 'cause you're now Chief Innovation Officer. Yeah. Well, so this is going to happen through consumer push, you would guess. Right? So my daughter's 27, she expects a digital healthcare system, and will differentially go to whoever provides her a digital healthcare system.

Right. So the marketplace will end up creating a sense of urgency to do this. Absolutely. Well, John, thank you as always informative and enlightening. I appreciate it. Absolutely. Thank you. . Thanks for listening. We have several other great interviews from has 19. Uh, please check them out on the website, iTunes or YouTube, and, uh, please come back every Friday for more great interviews with influencers.

And don't forget, every Tuesday we take a look at the news that is impacting health. It. This shows a production of this week in Health It for more great content, you can check out our website at. This week, health.com or the YouTube channel this week, health.com. Just go to the top, click on the YouTube link and it'll take you there.

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