digital strategy

Gerald C.Kane

How Digital Transformation Is Making Health Care Safer, Faster and Cheaper As chief information officer of Beth Israel Deaconess Medical Center, Dr. John Halamka oversees digital strategies that are designed to make patients safer and healthier while cutting medical costs. “We’re able to manage risk because of this digital footprint,” he says.

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How Digital Transformation Is Making Health Care Safer, Faster and Cheaper DR. JOHN HALAMKA (BETH ISRAEL DEACONESS MEDICAL CENTER), INTERVIEWED BY GERALD C. KANE

As chief information officer of Beth Israel Deaconess Medical Center, Dr. John

Halamka oversees digital strategies that are designed to make patients safer and

healthier while cutting medical costs. “We’re able to manage risk because of this

digital footprint,” he says.

Dr. John Halamka, chief information officer at Beth Israel Deaconess

Medical Center.

“What I have to do across 2,200 employees, 83 locations,

4,000 doctors and two million patients is try to take a best

guess at what the future will be,” says Dr. John Halamka.

Halamka is a medical doctor (his specialty is emergency

medicine), but he has spent his career focused on

bringing technology to the medical world.

As chief information officer at Beth Israel Deaconess

Medical Center, Halamka is responsible for clinical,

financial, administrative and academic information

technology for one of the world’s leading hospitals. Based

in Boston, Massachusetts, Beth Israel Deaconess is an

academic medical center affiliated with Harvard Medical

School. Its services include cardiology, obstetrics,

gastrointestinal disorders and cancer care.

Halamka has been in the CIO position since 1997. Back

then, he says, he personally wrote the code for the

company’s health information exchange and for the

foundational work of Beth Israel Deaconess’ electronic

health record system (known in the industry by the

acronym EHR).

Today, he doesn’t write code. “The nature of what the

digital guy does today is more about influence and

organization,” Halamka says. His job is to help coordinate

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the integration of digital technologies across the dozens

of medical locations and, increasingly, right into patients'

homes. And he does it in an industry of intensely, if

understandably, tight regulation.

In a conversation with Gerald C. (Jerry) Kane, an

associate professor of information systems at the Carroll

School of Management at Boston College and guest editor

for MIT Sloan Management Review’s Digital Leadership Big Idea Initiative, Halamka explains what his five

primary digital strategies are, how he deals with the

challenge of finding good talent in a nonprofit world and

why he found Google Glass intriguing but not ready for

prime time.

You’re in health care and you’re a digitally savvy person. Set the stage for us: How is bringing digital technologies to health care different than other industries?

I have a $1.5 million fine if somebody sends a text with a

patient identifier in it. I’m betting that doesn’t happen in

most other industries. The constraint about data flows,

audits and security, is very significant.

Data integrity is very significant. What if data is

corrupted and your allergy is now missing? In another

industry, if a piece of data about you, say your frequent

flyer number, were missing, probably you wouldn’t die.

In our industry, there is zero tolerance for downtime. My

average downtime is six minutes per year. And people say,

“Were you asleep at the wheel or are you just dumb?

Babies could die in those six minutes.” Try to find another

industry for which six minutes per year, 24/7/365, is

considered an intolerable number.

And our funding is tight — in our company, we have

1.9% of the operating budget for health care IT.

So demand is high, regulations are significant and

funding is low. Those are just a few things that are

different about health care.

Tell us about what Beth Israel Deaconess Medical Center is doing with respect to digital strategy. What is you digital strategy and how are you communicating that across the organization?

Sure. As we all know, health care gets better by getting

bigger. So mergers and acquisitions are the theme of the

day. Of course, the Affordable Care Act now pays us for

performance and value, quality and outcomes, as opposed

to just more volume. So that implies if we’re going to

control all the means of production, if we want to ensure

consistent policy and treatment guidelines and keep you

out of the hospital and look at continuous wellness, rather

than episodic sickness, we do need more sites of care.

And specifically, patient-centered medical homes,

suburban hospitals, urgent care, skilled nursing facilities,

etc.

We have community hospitals, 20-, 50-, 100-bed

community hospitals for which MEDITECH [software

for electronic health records, or EHR] is currently used.

MEDITECH is fine for that size hospital, although with

every hospital we acquire, it’s a different version of

MEDITECH and a different configuration, a different

user experience.

So digital-strategy point number one is to take every

single-instance of MEDITECH in the empire, move it to a

single instance cloud-hosted web-enabled application. A

little edgy. MEDITECH has agreed, as we are the first

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customer for this, to host it and use a subscription-based

software as a service model for MEDITECH, with one

single instance for all our sites.

Digital strategy number two is ambulatory care. It turns

out, MEDITECH is not a great ambulatory system. So

you look at the world out there and you’ve got the Epics,

the GEs, you’ve got eClinicalWorks, you’ve got Athena, a

few others that are not doing so well in the market.

EClinicalWorks, a client-server–based application, has

been our incumbent ambulatory care system, but it is

very challenging in an agile world. Athena, cloud-hosted

subscription model, runs on anything anywhere; much

more agile. So digital strategy number two, move the

entire empire ambulatory care system to Athena.

Digital strategy number three is expanding

caremanagement. In a world where your funding is

dependent on outcomes and wellness, you need

something beyond an EHR. An EHR is fine for a single

doctor to do analytics, but it is not enough for population

health or care management. Two years ago, we built a

care-management medical record that today receives

thousands of transactions a day from disparate EHRs

across the empire. That provides a single, consolidated

view to care managers, non-physician folks, who are

looking for gaps in care and for deviations from protocols

and guidelines. It can be used for initiating visiting nurses

in the home, telemedicine, teleservices visits, scheduling

appointments, looking at activities of daily living and

social support. These are the sorts of things you need to

do to survive in a risk-based world.

So far, by the way, using that care-management medical

record, Beth Israel Deaconess care organization has

become the number-one ACO [accountable care

organization, tying reimbursements to reductions in the

total cost of care] in New England and the number-three

ACO in the entire United States. That’s because we are

preventing redundancy and waste, and we’re focusing on

keeping you well in your home, as opposed to seeing you

for more ICU stays or emergency visits.

Digital strategy number four is engaging patients and

families. They are seeing the notes written about them.

They are contributing to the records, structured and

unstructured data. Their devices in the home are

connected, like blood pressure cuffs and something like

Apple Watch one day. The idea is that you need data

about weight and glucometer values and various vital

signs if you’re going to look for interval change between

office visits and make interventions. The patients and

families articulate their goals for the visits, and the care

team then shows them progress against those goals. We

don’t want to give more care, we want to give right care.

Giving patients and families on BYOD [bring your own

device] devices the ability to see digital dashboards of

their communication preferences, care plan, goals and

progress certainly helps.

And then digital strategy number five is to make sure we

comply with all the various federal regulations, whether

that’s ICD-10, meaningful use stage one, two or three,

HIPAA rule, ACA, etc. Of course, we have done things

like leverage the state’s health care information exchange

to its greatest extent to achieve the various

interoperability requirements.

So that’s, in brief, the digital strategy, and that is probably

communicated to every manager and every supervisor. I

go to what are called leadership meetings to explain it. It’s

well known among the senior management team.

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Published extensively on my blog. Broadly communicated

in every stakeholder meeting I have with other CIOs

across both our community and the country. As well, at

Beth Israel Deaconess, we have engaged governance.

With all the board members we reemphasize the digital

strategy we’ve had in FY15 and what we’re executing in

FY16.

You have a very clearly articulated digital strategy. What have been the most significant challenges you’ve dealt with as you’ve sought to implement the various aspects of the strategy?

Well, strategy number one. Do you think that the CEO or

the senior executive business owners come up to you and

say, “Do you know what we really need? We need an

omnibus, continuous care-management platform for

population health and analytics that will help us

understand variations in cost and care, so we can

maximize quality, safety and efficiency?” No. The senior

executives say, “I don’t know what IT we need. I’m not

really sure.”

So how do you get a set of crisp requirements and

specifications that are going to be foundational to an IT

project? Or do you try to get together, bottom up, a bunch

of people and skate where the puck is going to be? You

guess.

In effect, what I have to do across 2,200 employees, 83

locations, 4,000 doctors and two million patients, is try to

take a best guess at what the future will be. That’s sort of

strategy issue number one. Not top-down command and

control.

Number two, budgets. In this world of declining

reimbursement, it’s not as if I have vast amounts of cash

to go try a bunch of things. I have to be extraordinarily

focused in my efforts, and be cheap. The entire cost of the

MEDITECH cloud ends up being not particularly

different from the costs that IT and the community are

incurring today. In effect, we’re doing innovation and

doing projects in a totally cost-neutral way.

Challenge three, compliance and regulatory burden. I

have to share more data with more people for more

reasons, but never spill a byte. Because if I do, I have a

$1.5 million HIPAA omnibus rule fine and the attorney

general crawling down my back.

In a world with change, the health care environment is

basically undergoing a radical redesign as we move from

fee-for-service to value-based purchasing. Every

stakeholder wants their own thing, maximizing each

individual silo. Governance is a real challenge. Saying no,

making sure the institution agrees on what we’ll do and

what we’ll not do, and trying to keep people satisfied

when they’re told no. That’s kind of hard.

And then finally, a strange thing. Most for-profit

companies will pay out generous bonuses, give you stock

options, everybody has a Tesla Charger in their parking

space. But in nonprofit organizations, I have very little to

offer employees to recruit and retain them. I am

competing with social media dot-coms and EHR vendors

that pay much better than I do. So recruiting and

retaining talent while I’m executing a digital strategy is

hard.

On that last point, how do you recruit and retain digital talent in this highly competitive environment? And what to do you look for?

The first is to find people who are mission driven. Do you

have any idea what the CIO of HCA [Hospital

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Corporation of America, a U.S. for-profit operator of

health care facilities] makes per year?

No.

He makes $3.7 million. That would be slightly greater

than 10 times my salary. That’s in Nashville. So people

who are working in nonprofit health care are not doing it

for fame or fortune. They are doing it because of a sense

of mission. And so you find people who really feel just

good about their making a difference.

Number two, you make the organization seem so

innovative and cutting edge that people want to work

there to be part of the next new thing. Beth Israel

Deaconess was the pilot site for Google Glass, the pilot

site for Apple HealthKit, we have the Apple Watch.

And number three, we create a family environment. In 20

years, I have never had a resignation of one of my direct

reports. You create a collegial place to work, where we

never have blame or negativity, and where we examine

the process that failed, not the person who failed. People

feel very supported in that environment. So it’s a

combination of mission and excitement and family that

seems to be successful.

What have been the biggest outcomes? What are the benefits that are being realized?

Our goal is zero harm. It is very difficult in a paper-based

world to reduce harm, but we haven’t had a handwritten

order in 12 years. Every single med is dispensed with a

triple check, with barcoded meds and barcoded delivery

and the pharmacist oversight. It’s all digital. So you

reduce harms — that’s certainly a significant outcome.

We have 80,000 monthly users of our shared medical

record, where patients and families are contributing and

looking and reading and engaging and securely

messaging their clinicians. That digital workflow has led

to significant patient satisfaction and patient retention.

We’re able to provide layers of decision support and

analytics that are probably greater than most institutions

because we have the data collection instruments and the

warehouses, data normalization and health care

information exchange. We’re able to manage risk because

of this digital footprint.

If you can look into your crystal ball, what are the biggest changes facing digital and health care coming in the next three to five years, or whatever timeframe you can project into?

How about a month from now? We all are seeing this

mass migration to mobile. Eighty percent of the website

accesses at Beth Israel Deaconess are mobile based. The

desktop is dead, the laptop is dying. Instead it’s tablets, it’s

mobile phones. For us, ensuring that our patients and our

doctors have the tools they need to do the tasks they want

in a mobile environment — while securing it — is kind of

an interesting challenge.

I mean, the number of security issues that we’ve had over

the last year — state-sponsored cyber terrorists,

hacktivists and organized crime. Embracing BYOD and

mobile in a world filled with an Internet that’s a swamp,

that’s a challenge.

What do you get excited about as far as how digital is changing health care? Do you geek out on anything? Do you say, “This is really cool, what we’re going to be able to do”?

I don’t geek out on anything. I’ve got a lot of equanimity.

Not high highs or low lows.

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But from personal experience — my father died two years

ago and my father-in-law four months ago — what you

realize is that there are gaps in our digital world we need

to fill. How do we ensure that physician orders or medical

orders for life-sustaining treatment, end-of-care

preferences, goals, are transmitted across the continuum?

Are they stored on your phone and then shared with a

caregiver? Are they on a registry where they can be

accessed by anyone? There are still a lot of advance

directives, health care proxies and physician orders for

treatment moving around on paper. It’s very

disconnected.

I think it’s increasingly important that we do get

information from the home of all kinds, which means

teleservices, telemedicine, care in the home. I believe that

Minute Clinic and those kinds of urgent cares will have

an increasingly important role. Walgreens is beginning an

infusion program, for example. So when my wife was

diagnosed with breast cancer, she was driving in on the

Mass Pike hours every week, when, in fact, there’s a

Minute Clinic 50 feet from our farm that now could

conceivably do her chemotherapy infusions. That’s lower

cost, with higher patient satisfaction. It requires that the

digital record be sent through the health care information

exchange, to share it with all the caregivers.

So those sorts of things — more connectivity, reaching

into the home, more patient centricity — those are

exciting.

Where do you find the time to stay ahead of what’s next, or what you could be doing, given new technologies coming on the market? How do you remain innovative?

It’s important to have an individual contributor pushing

innovation. Because otherwise, innovation will get lost in

the tyranny of the urgent.

Do you think that applies beyond health care as well?

Oh, I do. Do you think it’s IBM that makes the big

innovations? Of course it doesn’t. It’s the two or three

guys or gals who come together and innovate and drive

some new disruptive solution home. Not large, lumbering

companies. So whether it’s a person or a small group, a

skunkworks, it’s that sort of thing.

Tell us about your Google Glass project in delivering health care. Did it work?

I was asked to pilot Google Glass in health care. What we

decided was the use case would be the emergency

department.

The plan was this: We lock the devices in a safe. A

physician comes in, unlocks the safe, takes out a device,

puts it on. Logs in by looking at a QR code that is unique

to that individual physician. So a physician is now in the

department, on shift and logged into the glass. As they

walk into any room, they look at the door. On every door

is a QR code. The registration system assigns patients to a

room. Therefore, the physician knows which patient is in

the room they’re walking in. They can see the problem

list, medication list, allergies, laboratory results, care

plans and other things in Google Glass as they are talking

to the patient.

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So we went live with it and deployed it. It was, I think,

four pairs of Glass across eight doctors, who used it for

several months. And then we threw it away. Because it

worked flawlessly from our perspective, but the Google

Glass was a horrifically engineered device. Used a TI

processor that overheated. We had one pair melt. Had a

one-and-a-half-hour battery life. Wi-Fi didn’t roam. It

didn’t have Android updates. It had security problems.

So it was just a prototype that was not ready for prime

time. Of course, we think wearable computing is really

great and important, and we will be happy to use a device

in the future that actually works.

So you’re not using that at all right now?

We can’t, because it can’t hold a charge for more than an

hour and a half and they melt.

Wow. Okay. What about Apple Watch, you mentioned that one.

Yes. The idea was this: If you have a patient with, for

example, multiple medications, that patient may not

understand what medications to take when. So what if, on

the Apple Watch, you gently tap them using the optics.

You show them a picture of the pill to take. After they

take it, they tap the watch and you have a patient-

generated electronic medication administration record

showing compliance with medications.

And? How did that experiment go?

So I am a white male, and I have very little body hair, and

it turns out that the watch works fabulous on me. But if

the watch is put onto a dark-skinned person, especially

one with a lot of body hair, the sensors don’t work. Apple

in its release scaled back a lot of its health-related

telemetry goals, and focused more on fitness — how

much did I run, that sort of thing. We may get there, but

at the moment the design of the sensors just don’t work

for everybody.

We’ll see. It’s, again, kind of an expensive thing, and it

requires that you have your phone. So I think the jury is

out as to what adoption will be in health care.

So that’s two examples, the Apple Watch and the Google Glass, that didn’t live up to the expectations you had initially. How do you approach new technologies given these kinds of hiccups? Does it dissuade you?

Failure is a valid outcome. What I mean by that is, we’ve

learned that wearable computing is great, but Google

Glass is not. And therefore, let’s just wait until the

technology is ready. Or with Apple Watch, we may

discover the patients love it, and therefore it is a platform.

Or not, and that’s okay. We just don’t know.

My traditional final question, is there anything I should have asked that I didn’t?

Just recognize that as you talk to IT leaders, it is just really

hard to be an IT leader in the current environment when

you are being asked to change the wings on a 747 while

it’s flying. Total security, total reliability and stability, with

complete innovation at the same time. And so I sort of

wonder, as we go forward to the future, will people want

to take this role? Or maybe the role has to be recast and

the tasks divided across multiple individuals so they can

deal with the pace of change and the stress.

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