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John S. Lee, MD, an emergency medicine physician, was drawn to technology as a youth and thought he was meant to be an engineer. It wasn’t until his final year in high school, when he took an anatomy and physiology class, that the pre-med seed was planted.
Those dual interests have served him well over his professional career, as Dr. Lee took on clinical leadership roles increasingly focused on data, information technology, and electronic health records, including his current position: Allegheny Health Network’s Chief Medical Information Officer.
In this Q&A, Dr. Lee discusses the future of virtual medicine, how to make patient data more user-friendly, and what the health care industry can learn from Walmart and Netflix.
Bill Toland: AHN, like most large health care organizations, saw significant growth in its number of telehealth encounters and video visits during the height of the COVID-19 shutdowns. But those numbers have dropped as we’ve returned to a more normal operating state. How do we reverse that?
Dr. John Lee: Much has been made about COVID and how it has catalyzed this disruption in virtual health. At a base level, though, separate from COVID, we need a more fundamental reason to engage in virtual health, in a way that incentivizes both the patient and provider.
As a physician, I suspect that 80% of what we do in medicine can be executed through a virtual mechanism. Now, you still have to physically come in for such things as diagnostic testing. But physicians can carry out a lot of their work in a way that does not require you to spend time driving to the physician's office, parking, waiting in the waiting room, waiting in the exam room, having a five-minute encounter with your physician, then spending more time checking out and driving home.
Bill Toland: That’s the legacy state of how we deliver care in this country.
Dr. John Lee: But that can change. Routine prenatal care, blood pressure control, diabetes control, even things like case management after a complex medical encounter in the hospital we can do that all virtually, or use virtual medicine as an added layer of care.
Take the complex medical encounter as an example. You get discharged from the hospital, and you have a follow-up appointment a week later. A week later? Really? If you're really sick, any number of things can happen in a week. Why not have a quick virtual encounter with your doctor that night? Let's say you're discharged at 4 p.m. Somebody checks in with you at 8 p.m. by video visit. “How are you doing? Can we go over the medication reconciliation with you? I see that your discharge summary is 50 pages long. I'm pretty sure you didn’t have time to read the whole summary can we go over a couple key things just to make sure that you don’t bounce right back to the hospital?”
Bill Toland: Assuming the technology is there, what are the main hurdles in getting to that point?
Dr. John Lee: Personal opinion? The top one is payment reform. We have to transform how we pay for care. As we continue to be episodic and fee-for-service, it's going to be a huge lodestone on our neck as we seek to change physician, patient, and organizational behaviors.
The second piece is data transparent, frictionless, semantically meaningful data. There is so much data out there, but it's not frictionless, not transparent, and not very meaningful to the end-user consumer.
Bill Toland: Too much noise, not enough signal?
Dr. John Lee: Sort of. The signal is in there, but we in health care have to devote new resources to finding it.
Data is the new oil. That's what's driving our economy. Look at what's happening with the stock market — it's tech and data companies, sustaining the rest of the economy. Because everybody else needs data and is acquiring it.
Walmart something like 11% of their expenditures are in data and analytics. The average health care organization spends 5%, 6%, maybe 4.5%.
Because of that, Walmart knows much more about us and our behaviors than our doctors do. The second that little Mary picks up a doll in their store and scans it through checkout, a signal is sent through their system to say, you need to make one more doll in that factory overseas. Based on the data we have, we can predict when Mary's going to buy another doll from that collection. Eventually, Walmart gets so good at predicting things that it knows to have the factory make that doll two months ahead of time, so it arrives at the moment Mary shows up in the store.
We are nowhere near that in health care.
Bill Toland: Why are they so much better at it?
Dr. John Lee: Health care is inherently complex, and we work within a very complex regulatory environment. Running a retail store is not the same thing as running a hospital. That said, it still goes to the incentive issue. The reason why Google and Amazon and Netflix are so successful is they have a very clear incentive, and that incentive is better aligned with the people that they serve.
This is why physicians complain about being the most expensive data clerks in the world. We’ve created a system geared toward incentivizing physicians to produce these pieces of data, these codes, that mean something to whomever is paying them. But these codes are only partially aligned with what is meaningful for the patient. We have to create a system whereby the payer, provider, and patient all have an alignment on what they want to produce, which is better care and healthier people.
Bill Toland: But we have a million providers and 350 million patients and thousands of employers and 50 health insurance companies. How can we possibly align when so many of us have competing interests and goals?
Dr. John Lee: It’s hard, for sure. People keep saying health care is like Blockbuster, and we need a Netflix to disrupt the system, to make it untenable for payers and providers to operate in the traditional way. It’s harder than that in health care, though. We have a systemic infrastructure geared toward perpetuating the status quo.
One thing that Netflix did, back when it was a mail-order DVD service, was to get rid of late fees. Blockbuster said, “Why would we get rid of late fees when so much of our revenue comes from fees?” Netflix saw a window there and exploited it.
But now imagine that a big government agency said for every DVD kept for more than two days, you have to submit a code that mandates a late fee. If late fees were mandated by a government agency, Netflix would have never gotten off the ground. So the analogy fails somewhat, because in health care, we have an entire industry infrastructure and regulatory apparatus with a lot of political and institutional power, and a lot of money. It's almost a fifth of our economy. So if those people don’t have the incentive to change, you're not going to change. At least not easily.
Bill Toland: We also have different goals in health care, right? Walmart wants you to buy as much product as possible. AHN doesn’t necessarily want that.
Dr. John Lee: It’s less about volume than about efficiency of delivery. But we also share goals with Walmart or Target we are all trying to make decisions based on data, and we are all trying to nudge outcomes. Have you seen the Netflix documentary, “The Social Dilemma?”
Bill Toland: It’s on my list.
Dr. John Lee: It's a little frightening. But as I watched it, the thing that occurred to me was that if we could use all this data for good, that would be such a powerful thing. And one of the industries where it makes the most sense to utilize this data for good is health care.
The big lift for us is behavior modification. It’s easy to change someone’s behavior so that they buy a pair of shoes they may not have otherwise. But eating better? Engaging in healthier behaviors? It’s just much harder to do.
Bill Toland: So how do we do it?
Dr. John Lee: I think one element is creating an intensely personalized health care framework for the patient, in order to drive that behavior modification. It has to go well beyond, say, telling the diabetic not to eat that extra piece of cake. If we incorporate specific genetic markers in a person’s care plan “Listen, the Mediterranean diet is good for most people, but it’s not good for your genetic make-up” we can deliver care in a much more precise way.
We can tell you most of that already. But how do we leverage technology to reinforce the message, and to change your behavior so that your health is improved?
Bill Toland: You said data needs to be transparent, frictionless and semantically meaningful. What does that mean in a health care setting?
Dr. John Lee: Ask anyone in health care who works in a managerial position how they go about getting data or generating a report or some sort of insight into clinical operations. They'll roll their eyes and say, yeah, that's a black hole. One of my goals is to ensure that 80% of the data that people need in health care operations is available on a completely self-service basis.
It has to be the same with patients. They need to have complete transparency and immediacy of what's going on with their care. There's an initiative called OpenNotes, where providers basically make their notes open and available to the patient through a portal, so that patients see what doctors are saying.
Bill Toland: Is there value in that?
Dr. John Lee: There can be. If you can read your doctor's notes, it makes you part of the treatment team. If the data is understandable, you can ask questions about it.
As a physician, there are any number of times that I've been saved by a nurse and occasionally by a patient who caught something in the notes that I might have missed. Once, in the ER, I had seen a patient with abdominal pain. We couldn’t figure it out, and I was about to discharge her and send her home with medication. Well, she had looked over the nurse’s shoulder and noticed that the mark next to her lipase test was red, when all the other marks were black. She asked me about it. I had missed the fact that her lipase was high, which is an indicator of acute pancreatitis. If I had sent her home, she would have done poorly. Because she saw that red mark, she ended up being part of the treatment team.
The key is making the data useful to patients. The problem with our current state of release of data to patients is that they don't know what to make of it. It's just this unorganized, undifferentiated mess of information. Even for organizations using OpenNotes, the open rate of patients who look at the notes is in the single digits. Intuitively, you would think the patient would want to see all this stuff but you look at it and it's just not that helpful.
Before you can modify their behavior, you have to modify the data we're releasing to them. That's where hopefully technology can help.
Bill Toland: I find MyChart to be incredibly useful. But for someone with a lot of health issues or patient visits, I think it could become very transactional. A lot of information about your next appointment, your last appointment, your prescriptions, your MRI results, how much you owe, lipid panel, but not a lot about your total health picture.
Dr. John Lee: Right. Translating that information is one of the roles of your primary care provider. They are supposed to have a grasp of your total health picture. But we often don’t do a good enough job of translating at least not good enough to modify behaviors.
Bill Toland: For the last decade or more, we’ve been hearing about consumerism in health care. Part of that is the look and feel of health care but data is a huge part as well.
Dr. John Lee: And not just personal health data the financial end is just as important, if we’re talking about true consumerism.
Say I cut my hand and call the ER to tell them I’m on the way in. They should be able to tell me, based on your insurance plan, you’ll owe $25. Do you want to pay right now? Other industries can do this. We have yet to introduce consumerism in a really meaningful way.
Imagine taking a flight, and then three weeks later you get a bill for $25,000, because you didn’t read the fine print the airline was in-network, but the pilot wasn’t. You wouldn’t be too happy about that. We do that sort of thing way too often in health care.
Bill Toland: Why do consumers and patients deal with that?
Dr. John Lee: It’s the only way we’ve known, I guess. Our system of care goes back to World War II. Once you have that inertia, it's very difficult to change. And when organizations are making money, there’s even less incentive to change, even when we can see that things aren’t working. One person's waste is another person's profit. And that person making a profit is very incentivized to make sure that the profit, and the system generating the profit, stays in place.
Bill Toland: That seems like a lot for a CMIO to tackle.
Dr. John Lee: We all have to tackle it. I read a cynical op-ed recently it said that, for the last 50 years, as a physician, your goal has not been to take care of patients. Your goal is to use patients as the raw material to produce billing codes, so that your practice or your hospital can survive.
When the incentive is to create billing codes, we’re not really taking care of the patient. We have to figure out a way to change the payment model, and change how we use data, so that every decision we make is about taking care of patients. That job belongs to all of us, including the CMIO.
Bill Toland: How did you end up moving from the ER to the EHR, so to speak?
Dr. John Lee: My entire life I've been drawn to technology. I thought for sure that I was going to be an engineer. But my senior year, I took an anatomy and physiology class. It planted a seed, so I applied to pre-med schools and I applied to engineering schools.
I got rejected from all the engineering schools and I got accepted in all the pre-med schools. So I guess fate was telling me something. But even as I was training and working in health care, almost all of my jobs ended up being technology-focused. At one lab research job, I was helping to do oncology experiments. I was using Lotus 123 a precursor to Excel to process the data. One of my supervisors saw me crunching the numbers and writing macros, and before long, that’s all I was doing.
It was like that everywhere I went. Jump ahead to 2006, at my previous organization I was still in emergency medicine, and we implemented a new records system for our emergency department. They thought we needed a physician subject matter expert. I got more and more involved, and my role at the organization eventually grew into being chief medical information officer.
Bill Toland: Will you still see patients here at AHN?
Dr. John Lee: Yes, I think it's vitally important that I eat what I cook. The tools that I recommend have to be something that I would find acceptable when I am working in the emergency department. And the only way for me to really know that is by seeing patients.
Bill Toland: You now work for a blended health organization, where the provider and insurer are integrated. Does being in an organization where the provider has better sightlines into the insurer and vice versa create unique opportunities for someone in your role?
Dr. John Lee: Yes, some of those efforts are already seeing results, and some are embryonic. My predecessor, Dr. Robert White, had a ton of difficult foundational work to do to get us to this point. I am extremely grateful for him and his efforts. Now that the foundation has been laid, I think the collaboration will become even more robust and more straightforward.
Bill Toland: Finish this sentence: When I’m not at home or at work, you’ll find me…
Dr. John Lee: Given the COVID crisis, I haven’t left the house much. But one thing I really like about Pittsburgh, which I didn't understand before I got here, is that there are a lot of outdoors opportunities. We don’t have as much of that in the flatlands of Illinois. Lots of corn, but not as much skiing or white-water rafting. Also, I do martial arts every day Pa Kua and Hsing I, sister arts of Tai Chi.
Bill Toland: Any reading that you’d recommend?
Dr. John Lee: “Predictive Analytics,” by Eric Siegel. It makes a nice companion to “The Social Dilemma” documentary. They address a lot of the same truths and insights they both speak to the power of motive and incentive behind these tools. Because, while these tools are powerful, power is neither good nor bad. It’s just power. If we, in medicine, can harness that power to do some good I want to be on that side of things.