SXSW 2018 – The Cure: Hospital Technologies That Work Together

all right good morning my name is
Susanne Palmer and I’m from the Johns Hopkins Applied Physics Laboratory and I
have the great pleasure and honor to be here with Vice Admiral rocky Bono Vice
Admiral and dr. rocky Bono who leads the entire defense health agency so we’re
gonna take about 30 to 40 minutes this morning and just share with you some of
our perspectives on the challenges associated with healthcare and
healthcare systems that don’t work together and talk about some of the
opportunities that we see in terms of connecting systems and how that can help
improve efficiency and outcomes for patients so just to give you a little
perspective in terms of where I’m coming from I mentioned I’m from the Applied
Physics Laboratory this is a separate part of Johns Hopkins University from
the Medical School but we work very closely in this space but the Applied
Physics Laboratory is actually a systems engineering organization so we build
large-scale complex systems and we do things like send spacecraft to Pluto if
you guys remember any of those really cool images from a couple of years ago
and we’re about to launch another spacecraft to the Sun this summer so we
do everything from space through air land sea and under the sea which is
where I spent most of my career so the first 18 years of my career were spent
developing advanced capabilities for our submarines I’m an electrical engineer
and so when I started working in health one of the things that I needed to get
smart on was what are the major challenges in healthcare and how can a
place like APL bring engineering capabilities and expertise to improve
healthcare so I just want to share with you a little story my very first
experience trying to get smart on what the challenges in healthcare are had to
do with a tour of a cardiac catheterization lab so as many of you
know a cardiac cath lab is where you go in for this procedure it’s not
open-heart surgery but it is messing around with your hearts so kind of
important okay it’s like clearly you can tell
she’s not a doctor right I got that out there yes you’re gonna see that today
but so as a doubly who spent her career working on working on submarines coming
into a cardiac cath lab it looked kind of like you know a regular operating
room and the clinicians talked through the procedure that they perform there
you know so they have this catheter that gets inserted through the blood vessels
works way over to the heart and they you know look at the function of the heart
make some measurements look at the arteries see if there’s any blockage
make some real real-time decisions about whether angioplasty is needed or some
other kind of procedure and as they’re describing this they’re talking about
some of the data they’re collecting right so they’re taking x-rays there’s a
little camera at the end of the catheter so they can take video and look at look
at what’s going on with a heart so I’m getting super excited and like geeking
out on wanting to go see what they do with all this data so after we kind of
get a sense of the procedure and talk about all these things we go over to
where the computers are and so I’m really excited at this point and I want
to see what they’re doing so they pull up an image and they start kind of
showing what we’re looking at you know here’s the artery and here’s what you
can see in all these things and so I asked what I thought was a
straightforward question about data fusion I said so you know can you pull
you know do you use data fusion do you take x-ray data and what you’re getting
off the video and all these things and put it together to form a more
comprehensive picture of what’s going on in the heart and you know I might as
well have been speaking a foreign language they didn’t kind of looked at
me like what in the world are you talking about it was that third eye in
the middle of her forehead I thought that spot right so I was like okay you
know data fusion maybe that’s a little advanced how about some simple like
simple tools right that can help you make certain measurements or identify
maybe where there are some problem areas it sort of help the doctors and the
nurses focus on the things that were that we’re
it’s critical and you know again I’m talking through and they’re kind of
looking at me like a roadie talking about them they finally said oh yeah we
have tools and you know they pulled out their state-of-the-art mouse and
trackball and proceeded to show me how they can you know point and click on the
artery walls and sure enough a number pops up that represents the distance
between those two points and so that was like a really interesting learning
experience for me and it really you know kind of showed me what my mission in
life is going to be which was to figure out how we can take all of these
advanced capabilities which you know all these things I’m asking about are not
super advanced they’re sort of you know basic engineering and algorithm
development and and we have way more advanced capabilities in other areas so
I wanted to figure out how can we take all this great technology development
that’s been done in other industries and bring them to healthcare to help improve
efficiency and effectiveness of care and so you know that’s that’s kind of where
I’m coming from but as you can imagine Admiral Bono has a very not that not
that Suzanne’s perspective is any less I mean I was pretty proud when she got to
the part about the click ball yeah but let me just so I think that’s a very
unique perspective do you mind if I ask how many of you are in health care ok
how many of you are in health care and IT all right how many of you are with
vendors you need the vendors in here yeah we need ok so here what what you’re
gonna learn here is what you need to save the vendors okay because that’s the
whole part that’s what our talk is all about
so as the Sen said I come from it from a slightly different perspective but but
what she just set up for me in and shared with you is exactly the piece
that I was experiencing from the medical side a couple of things about me I’m a
surgeon by training a trauma surgeon so there’s I’m used to a lot of chaos and
I’m used to navigating through that but it put on top of that not only am i the
director of the defense health agency where we look at the health care across
army medicine Navy medicine and Air Force medicine I also happen to be in
the military Oh mood lighting okay y’all feeling real
relaxed now I know that I have a couple of slides here that I just kind of want
to show you where I’m looking at interoperability and and how it plays
out for me because we take the military health complex we’re looking at medicine
and both the military aspects we’re which are two very complex areas and
bringing them together but what we have in here is we have to be able to deliver
care down at the pointy end of the spear down in the battles battlefield and
oftentimes what we’ve got down there in the bowel field taking care of our
wounded warriors or as as first responders our text medical enlisted
Tech’s technicians who are oftentimes a
corpsman or a medic or med tech who have the requisite training to do the
resuscitation but we need to make sure that we’re capturing what’s happened
downrange because at the next point of care we have to get them back to where
we can offer them definitive care so what happens at at in the battlefield
and then oftentimes when we transport them in the back of a blackhawk
helicopter which is very analogous to patients being transferred or
transported in an ambulance so how do we capture that care and how do we make
track keep track that especially as we bring them to the higher echelons of
care whether we go to the back of a very large airplane where we have a ICU set
up or when we eventually get them to a fixed facility in MTF
and so all of this equipment needs to somehow interface and and make it so
that we have that that fidelity and our data about what’s happened with our
wounded warriors as are going forward but for me in the military health space
it’s even more than taking care of people in uniform it’s being able to
take care of them once they transition from their uniform and oftentimes into
the VA or other parts of the of our environment or our society where they
need to get additional care so again being able to have that integration and
that interoperability of our health data our health systems is extremely
important now in addition to those the veterans then we also take care of
family members and so in the military health system we have new
ten million beneficiaries we have over 350 hospitals that are within cross
CONUS continental united states and overseas so there’s a real imperative
for us in the military system to know how to
keep track of this kind of this kind of data so as we’re looking at this the
other part of it that that is a big driver for me as I’m looking at what we
can do to improve this interoperability is how well can I also keep that that
information secure because as being part of DoD I have a heightened awareness of
cybersecurity now I hesitate to to say this in front
of the crowd and if I if you repeat this and you say you attribute it to me up
I’ll probably have to come find CQ out okay I’m just fair warning okay but part
of the reason we’re sensitized in DoD about cybersecurity is we know what it’s
like to be constantly cyber attacked but you should also know that your military
is very well-versed in how to be a cyber aggressive aggressor as well so we know
where some of those those opportunities are and we also know that the military
space is not the only space where we are at risk for cyber
so I want to put that out there and I hope that there’s somebody out there who
will challenge me on that or challenge us or want to engage in that
conversation so as we go through the military health system what you’ll see
is that we’re very much a microcosm of the healthcare environment for the
United States for our nation and because we have a relatively large presence we
are as a health care system where the seventh largest health care system in
the United States we hope to be a part of the conversation with the rest of the
healthcare environment so we can make progress in moving towards better
interoperability and then one other part of my intro here is that you’ve probably
also heard a conversation about how DoD the Department of Defense and the VA the
Veterans Affairs are going to start partnering and I think this is
incredibly important because now we’re talking about over 20 million
beneficiaries whose data we’re going sharing across the DoD and VA and being
able to have that interoperability with the VA is going to be exceedingly
important for us and and and as we combine our healthcare systems that’s
also going to elevate the size of what our healthcare in the men in the DoD in
the in a federated ecosystem will look like and I think the thing that’s very
exciting about that is moving towards that collective decision-making and
aggregating that at decision-making power and and just just to give you kind
of a baseline of what kind of numbers that means is that for my health care
system it’s a 50 billion dollar a year industry and for my my equipment
replacement you know my life cycle and and equipment replacement
I’m usually spending about a billion dollars a year I don’t know if that’s
the right amount but I think that that this is something that I would hope that
industry and vendors would pay attention to so I look forward to some of some of
the comments here but I know that that Sam and I have some other things that
they were going to be talking about but you know if it’s okay with you if they
if you guys want to interrupt us feel free okay because this was you know
truth be told I want okay I want to know learn from you so mostly personnel personnel and our
infrastructure also what we also do is a good portion of that is actually I
purchase care I purchase care from the civilians and so that’s another that’s a
great question thank you for reminding me because that’s another another
interface of interoperability that is exceptionally important to me yeah so as
you heard Admiral Bono has a vast space to worry about and very complex
challenges to deal with not only interoperability and commonality across
the United States but internationally but the thing that I wanted to spend
just a few minutes about talking about is the fact that we don’t even have
interoperability within a single room right now right so we’re thinking about
you know across hundreds of hospitals and clinics we don’t even have it within
a single room so one of the experiences that that really kind of hit home on
this topic for me in addition to the cardiac cath lab story working in the
ICU with dr. Peter Pronovost one of our colleagues who’s an intensivist you know
but as soon as you walk into an ICU the first thing at least that struck me were
all the alarms going right that’s sort of we’ve all heard about this and the
fact that nurses respond on average to a false alarm every two minutes right so
so as you think about that again this is within the ICU so you have like the most
critical patients in this area you’re responding to false alarms that’s a huge
efficiency issue but also over time those things are going to just be
drowned out right in the background and I understand that you know every new
system where every new device that’s developed they work really hard to make
sure their alarm is like the loudest and most annoying of all of them so then so
that they might get a response so you know not only is it a problem for the
clinicians but what about the patients right who are supposed to be recovering
and there’s constantly alarms going everywhere so one of the you know simple
ways to address false alarms is by looking at multiple sources of data and
again you know you’re gonna hear a common theme here but bringing together
different sources of data and using some very basic logic and algorithms to you
know to make sense of those is a really easy way to bring down false alarms
significantly but what does that require it requires you to be able to share that
data right so we need to be able to develop systems where you can actually
aggregate this data from different systems in one place so that we can work
to do things like beat down false alarms so I mean that everybody in this room
probably has a different example right of how we could do better by combining
data so there’s an endless number of examples but you know from the technical
side it’s not that hard and that’s the part that’s so frustrating I think is
that when you look at this from a technology standpoint we know how to do
these things and I think that’s one of the areas that you know Amaral bono and
I have spent a lot of time talking about is that we have lot we have proofs of
concept and you know we can talk about that a little bit later on but you know
this isn’t a technical challenge it’s a cultural challenge it’s regulation it’s
policy and it’s the fact that healthcare is not a centralized industry right so
there’s there isn’t that one decision-maker you know that one
authority but that can say here’s how we’re going to move forward here are the
standards we’re going to use here’s how we’re going to exchange the information
and so that’s one of the reasons that you know I’m so excited to be partnered
with Admiral bono because you know as she discussed the seventh largest Health
System in the country that’s that’s a force right and that’s a way to try to
drive things in the direction that we need in order to help figure out how we
can have interoperability across our systems and you know having been a
critical care intensive as a surgical trauma surgeon – I mean I know what
those alarms are and they can be annoying but but being able to make them
relevant in something that you that you need to respond to is is something that
I always was frustrated with – so it’s it’s gratifying to know that the
technology is out there if I can kind of expand that that that aperture just a
little wider – in terms of this entry bility so within our health care system
in the military I have over a hundred and eighteen thousand IV infusion pumps
you know that’s a lot and that comes from eleven different vendors and so now
you starting to talk about okay well what would we need to look like or what
would we need or what kind of decisions would we need to make to get to that
better interoperability so here’s the other thing that’s happening in the
military health system is we’re also launching our new electronic health
record now I know there’s a lot of competition out there and so I’m going
to go ahead and just tell you that we got the Cerner product and I know I know
there are probably some epic people out there but our our big thing and I and I
wish there are more vendors here because part of what you want to pay attention
to is how do Dee is moving migrating towards more of the commercial solutions
and this is an important driver for us now in terms of setting up our health IT
in our digital environment because now as I look at those IV infusion pumps I
want to make sure that those infusion pumps interface actually interface with
our new electronic health record and and as a family was was was describing to in
an ICU you know ideally we want all of those medical devices to be
communicating with each other I mean what a concept right
and I earlier brought up the part about security ideally I would also want to be
able to have these medical devices that sat on my electronic health record and
talk to each other to also have the kind of cyber programming that’s necessary to
keep it to keep that data secure so as I’m looking at that and I’m trying to
figure out what kind of decisions should I make as a director of a very large
healthcare system in terms of what kind of medical devices I should be putting
on my system and in another aspect for those of you that are involved in this
being able to select medical devices and in this case infusion pumps that are
interoperable or that interface with our electronic health record system that
also talk to the rest of my medical devices and it also provide a level of
security that I need now I can also start tailoring the training that I need
because the piece that I’m also looking for and I showed you a couple of slides
on this is how well does that IV infusion pump get ruggedized enough that
I can take it downrange to use in our in our hospitals and our our mass units or
our fleet hospitals or a hospital ships and what kind of benefits or
efficiencies could I gain by having the same type of IV infusion pumps that I
train our folks on in our hospitals that are in the United States and then when
they get deployed to go downrange they encounter the same medical devices and I
don’t have to worry about the training and then finally and you know when I
went through medical school I would have never thought that I could hear myself
talk like this now in terms of my life cycle management I now know I can start
predicting what kind of tech refresh and what kind of replacement you know cycle
I should use for the replacement of my infusion pumps so it’s it’s a much
larger conversation but I think what we’re trying to get here is is paint the
picture that part of this is a very large ecosystem in which everybody has a
has a role and it’s how do we how do we aggregate that and how do we move
towards more collective decision-making I grew up in the financial district when
we went through I’ll try all combinations confusion we
had breathe so we moved a lot faster instead I would like use your system
these are the standards of communication we are going to use I can’t believe it
Cerner epic or GE centricity or whatever you want to hit would not switch over
and customize vua you can leave the standard have you tried
yes yes that’s exactly what we’re doing and that’s actually what brought us
together is that in procuring our our sir we’d actually put in our RFP request
for proposal those types of requirements and as a matter of fact Cerner was the
first electronic health record system to get a DoD ATO authority to operate
because we had set that as a requirement for our security and so when we did that
successfully and we started looking at the other parts of our health care
system this is when I met with with others at APL saying well what could we
do to drive that behavior in the market and so as I’m looking at medical devices
and as I’m having my industry days I’m being very upfront with here the three
things that I’m looking for and I’m not interested in buying a proprietary
Patchen you already know based on the numbers that I shared that we we move
large sums of money to make this happen so I would hope that would be something
that people would pay attention to now and so we and I kind of alluded to it
not only are we a microcosm of the healthcare environment I believe that
the military health system can help inform and shape the way the healthcare
system will evolve we that in in the military health system our doctors work
for us I mean they are part of we also own the health care plan and many and
almost all of our patients they start off with
us and and so we’ve got the three legs of the stool for you know health care
and I’m very interested in partnering not only with industry but universities
and thought leaders to figure out how can we create some of those drivers to
to create that change and so that’s exactly what we’ve been doing is working
on how do we set the conditions that when we move into the marketplace we’re
letting the vendors know this is what we’re looking for and and we need you to
do this because of XYZ all make hell yeah and you filled up all talking
the same way utopia yeah if I could just get no clean
that you know I loved your question because that is exactly where we came
from in terms of this approach but I’ll share with you that in talking with some
of the leaders on the civilian side you know when we I mean DoD knows how to do
RFPs and how to say these are our requirements right on the civilian side
not so much so when when we started talking about you should say you know
here are requirements and we require these communication standards we require
interoperability and the response was why would they listen to us you know
they just show us what they have and we kind of pick from what they have we
don’t really tell them you know exactly what we need and then they’re not going
to change what they do for us and so again you know as you rightly pointed
out that’s where the the military health system and the DoD can really help drive
that forward and so let me just take it a step for and then I’ll take that
question next because not only did we set that up in our RFP because of the
way the defense health agency is is structured part of my portfolio is also
the logistics the medical logistics so once I find and I’ll just use IV
infusion pumps as an example once I find that sweet spot of the four or five IV
infusion pumps that meet all my criteria and then I can really start optimizing
the training and the lifecycle management that’s all I’m going to put
on my catalog for logistics so when when hospitals go to order the IV infusion
pumps are going to get a drop-down menu and they’re gonna have those five ones
that or whatever that final figure is exactly exactly now as a surgeon I also
know what that’s like in the or for those of you that are run ORS and do
this apply and equipment of ours that would also mean that we would not have
like a gazillion laparoscopic sets so you would have the few that actually do
what we needed to do and and then we can start targeting our training and making
sure that we we sustain that yes ma’am they don’t have a lock on market so it’s
in their interest in his immunity phase proprietary and not allowed this massive
interoperability you have everybody through fusion pop
works together I know competition sucks doesn’t it I
mean yeah that’s right you know and and and I think that’s one of the things
that that we’re actually asking for from the healthcare leaders is that let’s get
together on this so that we can drive that kind of level of performance that
we actually need as a provider I know how it is to be approached by the
vendors and and be shown the next shiny object you know but but that kind of
appetite needs to be channeled towards a more enterprise solution yeah and and
that attitude is certainly what we’ve experienced in other sectors that
transition from sort of you know the research was behind the
the best product right right and so that’s what you know creating these open
standards allows for increased competition it allows for the small
companies to come in and present their best solution that can be integrated
into the system so that’s certainly something that we’re expecting but I
think you know I think industry sees that this is where things are going
because we have a conversation a few weeks ago when we were talking about
there right there you’ve probably all familiar with fire in hl7 and all these
things right so there are standards out there and the discussion is shifting
toward interoperability and we actually had some some you know heavy-hitter
industry reps who were saying hey just tell us what you need you know we’re
happy to design to whatever requirements you give us and that was surprising it
wasn’t there was yeah but I think that was encouraging too so I think that yes
and I didn’t mean to denigrate in any way competition I think that’s great
and yes I think that as we move towards that then it should raise the bar for
everybody and then and that that should bend and be able to give us some choice
but I think the other part of that is how well as as a sector of this society
in the market how well can we come together and aggregate our collective
decision-making to drive some of this change yeah so one of the other I think
the other considerations there’s been a lot of talk of interoperability at the
electronic health record level right and so we kind of talked about it at
different levels that’s sort of at the macro level exchanging data across
health systems with the electronic health record but I think you know a lot
of what we’ve talked about today when when you drill down to the patient
facing you know medical devices that seems to be a more difficult situation
just because as Admiral bono said there are so many systems out there and
everybody has their favorite and so it’s not only the challenge of just creating
the standards but it’s also trying to get to some level of commonality so
particularly for the DoD as you train on one system you know you’re not having to
learn a different system everywhere you go so I think there you know there’s a
scale and there you know a breadth of challenges all the
way from EHR to EHR and down to minimal device interoperability it’s sort of
everywhere in between you know another one of the things that was sorry it’s
now Antony was you know I learned that within a single Hospital nurses spend on
average ninety minutes nine zero minutes trait tracking down a prescription that
was ordered right so doctor puts in an order for a prescription and it gets
filled and it’s delivered to one of like three or four places in the hospital and
there’s no way to track that so we’re not just talking about things that are
directly you know patient facing or EHR there’s even the different components
within a health system where you know logistics supply chain kinds of issues
can be simply fixed if we had better communication across these systems I
think that the opportunity is just and I’m sure many of you are sitting there
thinking since you’ve come from healthcare you’re thinking of a number
of examples where they’re just even a little bit of streamlining would make
not only your life but the patient’s lives a lot easier and we’re trying to
go with all of this is elevating our are all all of our performance so that we
can provide that reliable more safe environment for our patients we become
so large and clunky and while we technology drives a lot of that it’s
it’s being able to coordinate that and bring that together and integrate it in
a way that’s meaningful meaningful for our decision-making and meaningful for
our patients participation and care and I think that’s where we all need to you
know state that as our starting point and then ask ourselves what do we need
to look like and then the second question is what do we need to do in
order to get to that and one of the things that’s very exciting about what
we’re doing in DoD is finding ways that we can work with with a lot of different
people outside of the military because we know and especially in the military
health space we don’t have all the solutions nor do I have the personnel or
the talent within the military itself to find all the solutions so I’ve been
increasing that interface with industry and I have
numerous industry days but I also specifically target small businesses
because I think they have really creative solutions and what I try to do
is find ways that they can come work with us and and start scaling some of
their things to see if we can’t translate that across a much larger
environment so I’ve actually set up here in Austin with DI UX and other small
start-up places where they they’re very innovative and very creative and moving
towards giving them an opportunity to work with us and seeing what the kind of
solutions we can find I think that part of what we’re up against is how fast can
we do this how well can we make this how quickly how agile e can we make these
decisions and and start changing our environment and I think there’s a lot of
interest out there and you guys seem to represent part of that of that
healthcare that can help us create that momentum yeah so I just wanted to give
one example you know we we’ve talked about a lot of the challenges and I
think some of the possibilities and I really feel like there’s hope you know
we have we’ve done some proof of concept prototype development and deployment you
know one of the ideas was maybe if we can demonstrate their value in
interoperability that would be another way to kind of push the community toward
adopting you know standards for interoperability so we actually you know
back to the ICU we spend a lot of time focusing there and we actually developed
a system it’s called a merge if anybody wants to look it up eme rge but we
developed the system that was focused on addressing seven patient harms
preventable medical harms which of course everybody knows is the third
leading cause of death in the u.s. right so we developed a system that was
basically a dashboard and it ingested data from the electronic medical record
and it also ingested data from all of the sensors and systems within the
patient rooms and and the point of this was to create better situational
awareness for the clinicians I see you and so it had this dashboard
display that was really intuitive it’s you know kind of a red yellow green that
shows you which patients are at risk for particular harms based on the various
care that’s been provided and so rather than going through pages and pages and
pages of Excel files right in the health record to try to dig this up everything
communicated with the central system and so we deployed it in two separate
hospitals and collected data over a six-month period and we were kind of
worried because you know in six months so obviously it’s a redundant system we
couldn’t go in and replace anything so it’s a redundant system and we thought
well in six months are we really going to be able to see some measurable
differences you know with this system deployed versus without and we were
amazed we actually found significant increases in efficiency in terms of
clinicians ability to both identify patients at risk and then identify when
they hadn’t gotten certain required interventions and then we were also able
to measure improvements in outcomes so we were really excited that there’s a
paper that’s going to come out soon with all the details but you know that was
one example of how at a you know at a micro level we were able to demonstrate
the value so I think between you know the immense need and the community kind
of recognizing the value and then having some demonstrated results that show that
value we’re hoping that we’re going to to change the tide here yeah and I also
share that that optimism I think there’s a growing interest in this from not only
the healthcare side but from the consumers as well I think our patients
are really going to be the disruptive innovators and we need to pay attention
to what they’re what they’re saying and what they’re asking of us and really get
our minds wrapped around what does a healthcare two system look like or how
does it need to be designed in order to be responsive to what our patients value
you know assuming that all other things are kept even equal and you know in
terms of outcomes and safety to go along with that is another example being able
to use our medical data to get to that predictive
space there predictor for populations and individuals and then also to be able
to help mitigate some of the risks that we see I’ll use the opioid epidemic
right now as an example we did a proof-of-concept looking at all our data
but because I shared with you that many of our patients are taking care of in
the private sector being able to access that and combining it with our data in
terms of opioid prescriptions we’ve been able to identify which providers are
most at risk for providing the types of prescriptions that put our patients at
risk and we more importantly we can tell now with a great deal of sensitivity
which of our patients are most at risk for developing the addiction so that
allows us to act at a much earlier time in their care but we had to be able to
do that by sharing data across some interoperable interfaces between private
commercial and DoD and then and then the other part of that is is pulling our
patients into it so there’s a tremendous amount of opportunity here and it’s I
think it depends on the appetite that we have to addressing it and so we hope and
we were very excited to have this opportunity to just speak to you guys
because we think that there is this this growing interest in hopefully what we’re
trying to do is is create momentum towards that so I’d be willing to see
I’d be willing to hear what some of your thoughts might be or any of the
questions or examples that you might have because I think that what also is
also helpful for me anyway and I know that we talked about this I learn a lot
more from from the audiences and I think that I give to the audiences so I’m
interested some of the questions over here or we’re very good and the things
the the initiatives are working on are certainly gonna be shaped by what what I
hear here they’re very very good discussion now and I really
support you on the overall view okay we have to combine everything in the world
but on the other hand side my experience if you don’t start in the small cities
and the small areas you will never end it at the global view so we have to do
both yeah and I think you could do within DoD a lot more things
independently then together with others and even quicker because you are the
master of the data and if you use AI and whatever you can use many things and
this is what I would prefer if you could do this and go forward and then take the
others with you mm-hmm that would be my way for for for getting
health care really to the next level of technology I agree with you and I know
I’ll add that to my to-do list you’re exactly right and that’s and that is
actually part of the approach I’ve been trying to use here is that I
I see our military health system as having what we were talking about
earlier this morning is a corporate social responsibility and part of that
corporate social social responsibility is contributing to our society we do
that in kind of a mega fashion I mean there’s it’s not a secret that with some
of our mass casualty events in the United States Boston Marathon bombing
Las Vegas Madigan with the or Washington state with the Amtrak accident
Sutherland spring in San Antonio in all of those instances where there were mass
casualties DoD was there to partner with that and and and the care and the the
things that we’ve learned on the battlefield have translated very well
into the civilian healthcare space but you’re absolutely right in terms of our
role in helping to shape and inform how healthcare could go out to it you know
shape the the the private and commercial place I had attended about a year and a
half ago or maybe it’s closer to two years a seminar up in MIT
and I was listening to thought leaders and healthcare leaders about some of
their challenges and I thought that’s that’s the same thing that we’re
experiencing and what I offered to the group was that please watch the military
health system because I believe we can help find some of those solutions now
two years ago didn’t get much of a response today I’m starting to get more
of a response because I think that people do recognize that we can help
shape some of that both in opinion and in action so I appreciate that thank you
good morning hi it’s it’s wonderful that this is getting so much attention
because it’s you know so apparent that the fragmentation of the electronic
health record system is is a problem right there’s over 700 EHRs in our
country alone so this pilot is wonderful but I’m just curious because I’ve spoken
to other military physicians and know quite a few and they’re always like yeah
the military health care system is always five steps behind what other
technologies are so are you able to compensate for that do you believe that
that’s actually the case or thank you for bringing that up I I think it’s real
easy to fall into some of our institutional habits and and this gets
to the conversation about what does your culture allow you to do and in order to
create that culture my feeling is is this is where the we’re leadership
healthcare leadership is very critical because you need to have that at the top
helping to drive some of this down while you’re also creating some of the
solutions and the progress from below so to your question yes I think that we can
turn this much quicker we have a lot of dedicated interest in this and not only
in the military health system but as you may suspect my real boss is actually in
DC and there are a number of them who have a very strong interest in making
sure that we’re creating the most effective and lethal Department of
Defense military and so with that kind of impetus and that and
interest in reforming what we’re doing I think that we can we can turn that
pretty quickly the defense health agency is in a very unique position to drive
that and if I could just offer a slightly different perspective on on
that problem because you know at the Applied Physics lab we work both with
civilian and military health systems and what we found is that there are a number
of areas where the civilian hospitals are leading but then there are also some
other areas where military health is leading and one great example of that is
value-based care so you know everybody’s heard about that that’s like the new
buzzword well the DoD has actually done it and we’ve implemented a pilot that’s
now being scaled across multiple facilities and so we’ve kind of taken
that out of theory and put it into practice and demonstrated a lot of value
and improvement there so I think you know there are probably examples also
where the reverse is true but there are definitely some areas where we see
military health leading the way so good morning I’m probably one of the few
physicians in the room so it’s great to see dr. Bowen appreciated thing you do
for us I come from a different perspective so I’m a physician whose
career path has taken him in the direction of treating his own small
business and I went back and I got an MBA because I a lot of things that you
talked about today resonate with some of my frustrations as a doctor not seeing
things from engineering another more systemic approaches coming in a
healthcare and we see the opportunity there you know you talked about the
statistic on the third leading cause that doesn’t mean to me that’s a shame
that you know we have a tremendous healthcare system and we are some of the
best physicians in the world and and yet you know we have a culture generally and
I’m speaking to my own kind of you know being resistant to change at the same
time I think I have a very specific viewpoint on technology and you know I
argue that technology should be a tool right and many times I think we let
technological advancements or the opportunity to let technology improve
healthcare you know we let the tail wag wag the dog I mean ultimately it’s about
providing better care and and it ultimately has to be a tool
that’s usable and it’s effective for the physicians to be more efficient and to
provide you know being able to spend more time taking care of the patient and
believe me I’m an advocate for technology as opposed to many of my
counterparts that are you know that set against you know using EMRs or any other
technologies I might actually improve the efficiencies and interoperability I
know it’s a necessity you know I’m an early adopter of most
things and at the same time though I see that you know there’s a challenge
because operating mmm here our local Austin you know there’s competing
healthcare systems there’s competing politics and so every effort that I’ve
seen come up from any angle whether it’s University based our private industry
based has been thwarted by ultimately politics and you know whose market share
it is and that’s frustrating you know I I know you guys see that too but I think
I guess Tim and my point it’s not really a question it’s kind of a commentary is
you talked about it earlier you have all three legs and I think that’s a vital
standpoint you know we’re where innovation can really come from where
you know you don’t have competing interests you know theoretically you
have one goal in mind which is save money improve healthcare and improve
patient outcomes and I think that’s a unique position for you guys yeah
actually what you described is something that I’m very passionate about so
technology should be there to help support the clinicians and the patients
right and help provide them with better better information better decision
making tools and I think what’s happened at least in a lot of areas in healthcare
is like you said it has been the tail wagging the dog and so one of the things
that we try to focus on is you know what is that end goal what is the thing that
the clinician needs you know the decision-maker needs what information do
they need in order to be able to do their job and then let’s design the
system around that and I think that’s what’s you know part of what’s broken
right now with healthcare is we have all these tools out there the electronic
health record is just one example that lots of people are frustration with but
there’s lots of tools out there that are just here you go here’s another tool
it’s not necessarily taking into account the environment that it’s going to be
used in all the other tools that it needs to work with and how we can
leverage all those pieces to best support you know the end user so again
that’s a you know very system’s view of things but that’s one of the areas that
we’re trying to work on and improve but along that and chopping that systems
view I think is extremely important and and that’s that’s really the
collectiveness that we need to get to you shouldn’t be left out there by
yourself trying to do this on your own honestly right we should have an
ecosystem that supports this no matter where you are in the small rural areas
to the large medical centers I mean it needs to be part of the continuing needs
to be part of the the shared space and that’s that’s where we need to move
towards because we have the technological answers but they ought to
be designed in a very thoughtful way first I want to add on to that that
absolutely as software vendors for healthcare we go in and best of
intentions have seen this for 10 years we ask you what you want what we’ve the
dynamic is changing we are now going in working with you as partners to find out
what you need right what is the question you’re trying because typically what
happens is we want this isn’t this like okay fine we’ll build it for you we
could build anything we get there and we shoot right over what they were actually
trying to solve and it could have been much much simpler right we as vendors
have to get more involved in partner versus our beautiful production product
people that are in a box theoretically thinking what’s best for y’all because
until you’re in an operating room or in a patient’s office you don’t know right
you don’t know that that that second click is gonna be the one that stops
them from putting information in cuz there’s a pain the but it’s just how it
is so agree with that we’re trying we’re waking up but we were a little
egotistical for a long time about we knew better than the people who are
providing care well and I think part of the challenge though at least what I
found so is that when you go in and say what
do you want you kind of get a list of things that that are around the current
processing yeah or the way it was died so here’s everything I do help me do it
faster as opposed to there might be a different way to do that’s better
exactly and so so that’s what we’re trying to help provide is sort of that
vision of here’s here are the possibilities you know what if you could
have this and then they say oh yeah we’d like to have that right so it’s I think
it’s a combination of opening people’s eyes to the possibilities and then
helping them develop the capabilities to get there because you don’t know what
you don’t know and so you know we’re gonna continue
along the same path if we don’t start having and there’s a lot of times when
people will be like well why do you do step see we’ve always done step see
exactly okay so along those lines and this is extremely important this is
where the science is so important I mean we you we can make the we can design
these systems with data and we should design these the challenge though that
we have in the healthcare area and as a physician but it applies to any
clinician is our willingness to change how we do certain things and not
necessarily accept or be willing to challenge that just because we’ve done
catheterizations this way all the time is that the way we need to do this going
forward given the technology and the knowledge that we have today and I would
argue that that’s actually a part of the conversation that needs to be had up
front before we look at all these these elegant solutions is figure out is there
a more effective way of doing it and then in with the vendors and Industry is
helping us with your data to show why a particular system reengineer makes much
better sense than the way we’ve been doing it and my actual question I got
the microphone for was I’ve noticed that you’ve done some internal build versus
some by what are your criteria is for that Wendy decide which that which
option is the best one to go with I think it’s a combination I mean I think
from my perspective if there is something off the shelf
to solve the problem start there you need to reinvent right but for some of
the capability that we’ve developed it’s where we’ve looked around and we’ve yeah
we’ve looked at what’s there and we take where we can and then we build around it
where you know what capability doesn’t currently exist yeah yeah and we and
that’s what I mentioned earlier is that we’re going with commercial more
commercial in DoD so we’re starting there and the largest part the largest
challenge of that is the change management in how far does your customer
experience the patient experience way into purchasing innovation decisions
yeah so for the for us in the military health system large it’s it’s a book big
part it’s a driver that we’re really trying to get at more frequently more
consistently and more comprehensively in my mind for the military beneficiaries
for our beneficiaries our DoD beneficiaries my going in is this is
their health care plan and so I want to I want to understand what is valuable to
them what what creates value for them and I think it should be a given for
them that you know if they come into any one of our facilities for surgery that
they’re not going to have a complication that they’re not going to have an
infection that they’re not going to be readmitted that they’re not going to die
that should be a given so understanding what creates value for them in that
healthcare episode or in their healthcare experience writ large is a
big driver for us so what you’re going to see in the military health system is
we’re working on our access our ease of getting into into some you know clinics
or appointments the other piece of that is empowering them with their own data
and making sure that they have that that that is their data and that we’re
partners with them so the the patient the patient experience and their their
value system is what we’re taking into account largely as we as we reconfigure
our military health system there’s one work a lot of it honestly
boils down to hard work so in other words some of it is just how you decide
you know which partners you’re going to work with and no matter what you pick
there are things that you’re going to have to change and you’re things you’re
gonna have to work with so do you mind speaking a little bit about how you
decide which partners you’re gonna pick with that sort of work ethic in mind and
if that plays into how you decide who you’re gonna work with I’ve become very
discerning about who who I give the taxpayers dollars to they have to share
some of our values and they have to share our goals I’m I’m a steward of a
very large sum of money and it’s critical to me – your previous question
about how well we’re designing this healthcare system for our patients and
so I’m I’m very selective about the vendors that we work with thank you
I’m a physician as well and you just mentioned the patient experience and
that’s one thing that we’re really focusing on in my institution and
another challenge that I’m been working on is trying to improve the fit between
a patient and the provider and so I wonder here what is the DoD currently
doing in terms of when there was a patient with a certain condition how do
you find the right provider and to improve that fit and what does the
future look like for the DoD that’s a great question and I think you know the
way healthcare the complexity and of healthcare the space itself our
environment the complexity of our patients it really does take a team
approach and what I’m looking for and what we’re doing in DoD is making sure
that our our providers all providers all clinical providers are our team members
and that’s something that we’ve demonstrated how well that works
especially in Iraq and Afghan stand with our survivability of injuries
is that we find that when we we brought all the services together and combined
our collective expertise we had one of the lowest fatality rates despite
increasing injury injury severity scores on the on the battlefield so that is a
part of what we’re doing and that is that is it’s actually a continuum that
we’re working on in terms of the providers that we bring in to DoD I know
we’re kind of getting the hook Thank You actions and your participation

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