HIMSS 2024 Dr. Craig Joseph

Brian Urban:

Yes, this is the Healthcare Rethink podcast live at HIMSS 2024. We're talking to the biggest innovators, changemakers and doers, and we have one of those with us right now.

Dr. Craig Joseph:

You're also talking to me.

Brian Urban:

Dr. Craig Joseph of Nordic Global Consulting, the chief medical officer for that very large group, and also an author, Designing for Health. So we talked to him many months ago, but you had a great conversation on stage the other day really regarding digital transformation. But welcome to the live podcast, unscripted.

Dr. Craig Joseph:

This is great. And I did not realize that HIMSS existed for us to have this conversation, because I think everything else is extraneous and this is really where the magic's happening.

Brian Urban:

I agree.

Dr. Craig Joseph:

I'm excited.

Brian Urban:

Craig, I love talking to you because you are just full of life, but you're actually full of a ton of innovation stories. So you were a physician for many days back in the day.

Dr. Craig Joseph:

Yeah, many years even, some would say.

Brian Urban:

But you transitioned pretty quickly to the technology space, so you actually helped the shelf products at that time of Epic and deploying them across the US landscape. I want to take a look at what the technology was back then and what you're seeing now in terms of digital transformation.

Dr. Craig Joseph:

Sure. So I am a pediatrician. I practiced primary care pediatrics for about nine years. And then moved to Madison Wisconsin to work for a small electronic health record vendor called Epic. The reason that I and several other people were hired at the same time was to start a system by which you could jumpstart your implementation with an electronic health record. And in the olden days, by the olden days, I mean 20 years ago, when you got a lot of technology, basically it was like a box of Legos, bunch of little tiny things, and you got to put them together in any way you wanted, which was great, but also horrible because you didn't really know how to put them together and you thought you knew. Sometimes you got it right and oftentimes you got it wrong. So pre-configuring those pieces, so like, "Hey, we know that you're going to need this, and so we're going to give it to you." It's going to be 80% of the way there, which is a lot better than 0% of the way there.

So I think we see that a lot nowadays, things that are already configured for you. Apple is one of the companies that's kind of been way ahead in that, saying like, "Hey, we're not going to ask you. We're not going to give you a lot of settings. Most of you don't want to know about them. We're just going to have it work." And then you don't have to think about it and it's going to get most people most of the way there. We're seeing that a lot. And I think that's one of the things that's exciting about AI, that we've finally come to the point where it can actually help us.

Brian Urban:

Yes.

Dr. Craig Joseph:

We don't really have to know how AI works. We're not interested in knowing how AI works. It just works. Got to know its limitations, that it's not really intelligent, just seems to be intelligent, but if it gets us to 80% of the way in our task, we're happy about that.

Brian Urban:

So that's really exciting because what I heard you say is, a lot of the technology now is getting most people where they need to go. And it makes me immediately think about engagement, member, patient, really a person-oriented engagement. When you think about digital transformation now, it looks like there's so many different health technology vendors that are going into the broad space of digital health solutions. And then there's a lot of niche companies that are focusing on virtual health models as well: COPD, gut health, spine, everything, musculoskeletal. It's unbelievable. Is there too many vendors in this space? Or are we at the point now where we're starting to figure out who are the biggest impact makers that are actually engaging populations in some of their tools?

Dr. Craig Joseph:

Yeah. I mean, everything goes in waves in health care IT seemingly, or in health care in general. So sure, there's some new technology, some new functionality, there's going to be a lot of players. Some of them are going to succeed. Those will generally get eaten up, as we've seen. So I think we're always at a point where there's probably too many players. When you come to a big conference like this, there's going to be a lot of smaller vendors you're not going to see next year. So that makes sense, right? You have to try something new.

Getting focused though is, it's kind of the way to differentiate yourself. At this point, if you're trying to serve all the masters, you're never going to be successful. Kind of going in and saying, "Hey, we do this one thing. We do it better than anyone else. We do it in a slightly different way, just a little bit of a spin," that's great. Often you'll find a larger group that wants that functionality, wants that technology, wants to bring it in, and that's the way to go. I'm not concerned that there's too many. I'm not concerned that there's too few. It's generally a market self-regulating entity. It just works.

Brian Urban:

It's its own organism, healthcare tech and healthcare ecosystem in the U.S. definitely. So we're coming off the brink of a very large cyber attack on Change Healthcare.

Dr. Craig Joseph:

Yep.

Brian Urban:

A lot of good companies stepping in, wanting to help health care, wanting to play an important role in the recovery process here. I want to get a little bit of a prediction from you. Is this just one of many more cyber attacks that we're going to see hit the headlines beyond 2024?

Dr. Craig Joseph:

Well, we've seen a lot of cyber security problems and it's never going away. I think everyone is at risk for a cyber attack. You can be smart, you can do everything you can to minimize, but pretty much if there's a state player that's coming after you, you're at risk. It seems that the main problem that we're seeing now is, when you own a big chunk of the market and you're hit, the outcome is much worse than if it's a smaller player. This is happening, it's going to continue to happen. It's one of those things where it's just a cat and mouse game. So you can build to fix all the problems that you know of, and then someone finds a different problem that you didn't know about and there was no way for you to know about it. So I think this is how we're living. I think about it as TSA at the airport, right?

Brian Urban:

Yep.

Dr. Craig Joseph:

We had one, big, bad incident and ever since then we've been trying to play catch-up. So security changes. Sometimes when you go to the airport, even if you're a frequent flyer, they're throwing something new at you, and it's random. I've certainly had metal detectors at certain airports that seemingly are much more sensitive on certain days than others. I think that's what we're going to continue to see, is that probing for weaknesses. And they're going to find weaknesses, these bad players. So all we can do is continually try to plug them, make sure that the weakest link, which is usually humans, are as they can be with some of these things, and just keep trying to plug all the holes. But I think it's one of those things where it's impossible. I don't think anyone would tell you that. Even cybersecurity companies would tell you that they're immune.

Brian Urban:

Yeah.

Dr. Craig Joseph:

They're a big target and people would love to take them down. So they're going to keep trying. And again, when you have state actors that have pretty much unlimited resources in terms of money and people, they're going to make some forward progress.

Brian Urban:

What you just described there made me think of a couple of things: One, how can we get upstream? I think a lot of the different healthcare technology companies now were trying to get upstream with some of their solutions, not just from a security perspective, but also from an engagement perspective and also right-sizing healthcare cost perspective. So my question in saying all that is, back in your healthcare practitioner days, being a pediatrician, you face a lot of families, you faced a lot of complex problems that had simple solutions. Fast-forward now, do you think families and individuals are more taken care of? Or are they more distracted with all of the different healthcare technology that's facing them? Whether it's from a health plan or it's from their PCP or from their specialist, what is it like for a family now versus what it was back then?

Dr. Craig Joseph:

Yeah. So the answer to your question, this or that, is yes, right? It's both. I think the word that I like to use is disintermediation. It used to be, when I was in primary care pediatrics, that there were very few urgent cares. So the concept of urgent care was kind of new. If your child was ill, you took them to the family doctor or the pediatrician, and we would see them and we would see them over time, the same person. Now, depending on the time, depending on the city even, a lot of doctor's offices, well, if you don't call early in the morning, there's no appointment that day. And again, if you have a child, you're not going to be waiting days to get them seen. So you're going to urgent care.

Now, you're kind of cutting out the middleman, which used to be the primary care, it still is in some areas, but the primary care physician office. That's good and bad. Certainly, it's convenient. So yeah, now I can just go, I don't need an appointment. If you're lucky, your medical records follow, but clearly you're not seeing the same doctor time in and time out. And that's not good because a lot of the magic, a lot of the secret sauce of primary care in any country is you're seeing the same physician or small group of physicians over time.

Brian Urban:

That relationship.

Dr. Craig Joseph:

It's amazing. I saw a child once in the morning, and the mom's like, "I'm sure he has an ear infection." I was like, "Those ears are perfect." And then she called that afternoon and said to us, "She's much worse." "Now, bring her back. Let me see her." I look in a horrible, red right ear. It was horrible. It was just bright red. I told this mom, "Hey, if you would've told me you went to urgent care this morning and they told you that the ear was great, I would've told you they're horrible doctors. This is a horrible ear." But it was me. I saw it. So that was one of those instances where boy, seeing that patient over time, in that case it was the same day, but following the same patient over years, it's really invaluable.

No matter how much technology you have, how much coordination, and we have, in a lot of places, very little of the technology or the coordination. But even if you have a lot of that different people seeing the same family, seeing the same patients, it's not going to be as good as having the same person do it. So I think we're always trying to find that sweet spot of, "Hey, we want to make it convenient for you. We want to decrease costs. We want to make care more available." There's not enough primary care physicians in the United States for a number of reasons. So how do we find that sweet spot where we're not just we're looking at one family doctor to treat us totally, but at the same time, we are finding that continuity of care? There's no easy answer. So it's something that we'll always strive for, but I think we'll never achieve.

Brian Urban:

It's interesting that you mentioned continuity of care. Earlier in your explanation here, you're talking about the health journeys. So something that's always eked me in our industry is outcomes. Outcomes and closed loop referrals. Drives me crazy. Stop closing stuff. Have a view of it over time is my perspective, at least from a public health perspective. But from a practitioner perspective, what are you seeing now in terms of that patient provider journey over time? Are you seeing the data being a little bit more available for a physician to say, "Hey, you know what? I think there's some things we need to test in terms of cancer screenings, based on your family history and other branch of the treat," or for you individually as you're getting older, here's some things we need to line up?

Not closing it out, but making sure it's a really rich journey and then shared across the ecosystem to payers, to specialists, and to the vendors that are maybe supporting from a social health perspective. Is that infrastructure still just getting figured out? Or do you think it's going to be a real thing in the next five years, that it's in the healthcare ecosystem in the US, we have a better infrastructure of taking care of the journey?

Dr. Craig Joseph:

I think the infrastructure is in place. So I think we're at a point where the data are almost there. The right people have the right information. We're nowhere close, I think though, to actually leveraging that information, coming to conclusions. So it's one of those things where if I give you all these data and say, "Good luck, God bless," try to find something, right? And how's it actionable? So it's one thing for some smart person in an academic medical center or somewhere in our country's capital to have all these data and to know that, "Boy, that colonoscopy screening recommendation that we're using is maybe not optimal." Okay, well, how do we make a new recommendation? And then once we do make the recommendation, how do we get that out to the masses for the physicians and clinicians who are providing the care, how do we get them to know what the right thing is to do? Which I think kind of comes back to the technology. How do we make it easy to do the right thing?

We know that's impossible for any human now. It's probably been impossible for decades and decades for any human to know everything that's all the recommendations, even the basic recommendations. So we really need the technology to step up, A, to summarize what you're saying from a population health, and then B, to bring it to that point of care. It doesn't help for me to know that here's a long list of patients that need an intervention, they need a colonoscopy. How do I get them the colonoscopy? We're nowhere close with that. A lot of our care is episodic. We actually made incredible progress because of the pandemic in telehealth and making care virtual so that you could get it anywhere. The problems were never technological. We found this out when we closed down society, and two weeks later we're doing virtual care. Oh, my goodness. We knew how to do it. We knew how to do it, we just didn't do it because there were laws and the payment structure didn't allow it, right?

So when we instantly said, "Oh, let's not worry about the fact that you're a physician licensed in California. There's a patient over in Arizona who needs care, but you're not licensed there." So yeah, once you get rid of those things, those are anachronisms. They shouldn't be there now. They don't seem to make a lot of sense. Why is every state licensed their healthcare workers? Why do certain payers, most payers now cover in-person care different than they would cover virtual care when the outcomes have been shown so far to be very similar, if not even superior sometimes for virtual care? So we have to get with the program. But once we were absolutely moving in that direction, the pandemic was horrible, but did teach us some important lessons, that we know how to do a lot of things that we just never did. We thought were impossible, but they're certainly possible as long as we allow it. We got to get out of our own way. That's really what I'm saying.

Brian Urban:

Yes. I hope it doesn't take another huge economic downturn, global pandemic to make us snap back into reality of where we should be and have a stop looking retrospective and pulling it into the future. Something that you mentioned I think is really fascinating is the different populations that exist for an individual provider that they see on a daily basis, let alone a health system that is spread across a completely huge region like the Southwest, like the Northeast.

When I'm thinking about advancing interventions in terms of social health, you were mentioning having actionable data. So not just something a laundry list of how this person is struggling with X, Y, and Z. How do I get them the colonoscopy? Is social health data, a lot of organizations referring it to as SDOH data, is that going to be helpful if it's still outside of the payment structure? Or do we really need to fast track this and integrate it into an EHR and a simple cut of data, not a huge complex list of attributes, but something simple? Is that still the missing link, is they're just not in the payment structure? Because it's clearly connected to healthcare spend.

Dr. Craig Joseph:

So social determinants of health is the term, and I think most of that information is now in the electronic health record. So most of the HRs that I'm seeing here at HIMSS do you already incorporate it. It's available. It's available. Now, the question to you that you asked, which is the right question, is can we do anything with that information? Hey, it looks like you said that you're struggling to pay rent or to find a safe place to live. And then what do I do? What's the next step, right? Oh, I can refer you to our social worker. Okay, that's great. If you have a social worker, you can refer them. Do they have the bandwidth to help that person? If they do, and you do have a social worker and they do have the bandwidth, are there programs out there that you can help leverage to change their lives?

Sometimes the answer is actually yes. There's a lot of programs. There's a lot of money that's out there that goes unused because people don't know or there's some form that they're supposed to fill out that they didn't know about. So certainly it's helpful. I think the information, though, is so rapidly has gotten into the EHR. It's in the hands of the providers at this point, but their ability to do something with it is still limited. But again, step one is make them aware of the issue. That we've made tremendous progress over the last couple of years.

Brian Urban:

That's exciting because there's so much more work to do. There's so many different vendors trying to put their hands in on having a helpful fix to what's happening in our healthcare ecosystem.

So Dr. Craig Joseph, I got a question for you. It's kind of a wrap-up takeaway here. You've been at HIMSS now for about a day and a half.

Dr. Craig Joseph:

Yeah.

Brian Urban:

You're going on two days here. What's the big takeaway from you? Has anything blown you away at HIMSS 2024 that's going to impact some of your work the rest of the year here?

Dr. Craig Joseph:

I think it's just confirming what a lot of us have suspected, is that, I've said it before and I'll go back to artificial intelligence. It's amazing. It's amazing what's happened, to actually see this. We've got the compute. We've got the ability now to actually make applications and make use of some of the information in a smart way. So what we're seeing is groups actually make those data points that we've been collecting for decades and not really knowing what to do with it, making it available, making it actionable at the right time for the right person. And that's what I see a lot of people kind of coming to the forefront of saying like, "Hey, we can take that information. It's no longer just sitting in some river somewhere and we can deliver it again." The key is to get that last mile. That's what we've been lacking.

Okay, we've got the information we need to the health system. That's awesome. Did you get it to the doctor or the nurse? And did you get it to the doctor or the nurse at the right time? Right? So sending a doctor a list of things, at the end of the day, it's not helpful. I've got a patient in front of me, how do I know who of the hundred that have a need, who the 10 that I can actually reach out to today? I think we're so close to getting there. So we've still got lots of procedural problems. We've got financial problems that we need to kind of corral, but the technology's really exploding, and now we're seeing the applications of that technology in the real world. It's very exciting.

Brian Urban:

I love it. Promising outlook, confirming a lot of the tactics that are in place right now. Dr. Craig Joseph, chief medical officer, author. I don't know what else is next on your list.

Dr. Craig Joseph:

I'm looking to become an Olympian.

Brian Urban:

It's not too late.

Dr. Craig Joseph:

But I don't do any sports, so that might be a problem, but I'm working on it, Brian. Never say never. Positive attitude.

Brian Urban:

I love it. Thank you so much for joining the podcast, Dr. Joseph. Enjoy the rest of HIMSS.

Dr. Craig Joseph:

Thanks. It's my pleasure.