Friday, February 14, 2020

The Future of Elder Care

Last weekend I moderated an amazing group of presenters for Harvard Business School's 17th Annual Healthcare Conference, debating the future of elder care throughout the world.

Discussants were

Geoff Price - Oak Street Health, Chief Operating Officer

Susan Diamond - Humana, President of Home Solutions

Neil Wagle - Devoted Health, Chief Medical Officer

 We started with a statement of the problem - in many countries such as Japan, the Nordics, Germany, Italy, and the United States, societies are rapidly aging.   Birth rates are declining.    Costs are rising and access to clinicians is becoming more challenging

 We delved into several major themes - the role of home care, the rise of digital health, and the evolution of financial models that incentivize wellness over sickness.

Mayo Clinic is building home hospital capabilities and, later this year, will evaluate these efforts in two sites.    Through this early work, we'll learn about the supply chain, telemetry, command center capabilities, staffing, and the characteristics of patients best suited to home hospital care. 

 All of the panel members agreed that the future belongs to delivering high quality care in the right setting at the right cost.   Medicare Advantage reimbursement models, accountable care organizations, and alternative quality contracts all focus on reducing total medical expense while sustaining quality/safety/patient satisfaction.     If home hospital care reduces cost while improving outcomes, I believe that refined reimbursement models for home care will emerge.

Delivering digital capabilities - telemetry, communication, and care orchestration to elders requires a comprehensive technology strategy.   Many homes do not have fast, reliable wifi.    LTE and 5G cellular networks will be increasingly strategic for home care.     It's likely that a technology services partner will be needed to keep home-based devices configured, secure and stable. 

Just gathering the telemetry as part of elder home care is not enough.   Algorithms and analytics are needed to turn raw data into action, filtering signal from noise.   It's not yet entirely clear how to understand the precision/accuracy of remote monitoring, how to interpret individual variation, and when to ignore false positive signals.

Mayo Clinic is also launching a remote diagnostics and monitoring capability over the next year, via a platform approach that connects telemetry to novel machine learning algorithms, supporting patient wellness.

We also discussed the digital divide.    As we create more digital interventions to the home, we must meet patients at their level of technology comfort, literacy, and affordability.    We'll need organizations that can help patients access care, optimize the use of devices in their home, and encourage follow through with care plans.   

The future of platform components to enhance elder care is bright and an ecosystem of supportive businesses will be needed.  I look forward to being part of that journey.

Tuesday, February 4, 2020

Innovation at Work

Over the past 40 years I've worked in a variety of workplace settings, each appropriately serving its intended purpose. I did not appreciate how much a workspace influences my productivity and mood until I starting working at Mayo. My new role focuses on convening stakeholders and facilitating discussion.     A supportive workspace is transformational.

In my mid-teens, I worked in shared office space at TRW (a predecessor company to Raytheon) with large metal desks, filing cabinets and fluorescent tube lighting

In my late teens, I founded a company in a basement and worked at a drafting table next to a bed

In my 20's, while running the growing company and completing my medical education, I worked in a glass walled private office so I could watch the flow of daily activity.

 In my 30's, 40's, and 50's as a CIO, clinician and professor,  I worked in a cube but spent much of my time with customers in other people's offices.

For the past 2 years, I've worked in an open space ad hoc desk/meeting room arrangement that was efficient, attractive, and highly functional. 

Now, as I approach 60 at Mayo Clinic, I work in the most innovative and collaborative space of my career, the recently remodeled Mayo 11 administrative floor. No one on the Mayo senior team has an office - not the CEO, COO, CFO nor Presidents. Everyone uses open plan hoteling desks. The desks are surrounded by huddle rooms and meeting spaces that can be reserved via touch screen or calendar invite. Everyone sees each other every day for hallway conversations. I can ask the CEO any question, any time, by just walking through the space. There's a common kitchen area with meeting tables and healthy food offerings

The furnishings are simple - a kind of Zen functional elegance. Reminders about Mayo's vision, mission and values adorn the walls. The lighting is all 5000K LED daylight.  See photos below.

While rigorous days are common,  the time never feels long because of the richness of human interaction that takes place in the Mayo 11 space.

Per my previous post, my apartment is a 6 minute walk from my bedroom to the Mayo 11 office. I've shaped my new life routine around these living and work spaces for maximal focus and impact. I leave the apartment at 6am, walk 2 minutes to the skyway, which is a heated walking corridor connecting buildings in downtown Rochester. I arrive in the office by 6:10am, have breakfast, write goals for the day in my journal then review the day's presentation materials and agendas. Every 30 minutes from 7am to noon, it's easy to move among meeting rooms, some on Mayo 11 and some in surrounding buildings. A shuttle that runs every 5 minutes takes me to nearby St. Mary's Hospital where I spend time with my clinical and laboratory colleagues. By noon I return to Mayo 11 for lunch and a catchup with my colleagues. Meetings and presentations continue from 12:30pm until evening. The walk back to my apartment passes by a great market, an all vegan restaurant, craft breweries, and a boutique wine store. Dinner is usually a simple bowl of rice, beans and vegetables.  I spend the late evening writing plans and reading the briefing materials prepared by the Mayo Platform team, partners, and collaborators. 

From 7pm on Sunday night until 7pm Thursday night, I'm in Minnesota, living this very productive and satisfying pattern. I return to Unity Farm Sanctuary in Massachusetts by midnight on Thursday. Friday is a mixture of calls, video chats, and writing in my farm office.

On Saturday, I work with the animals and do complicated/time consuming farm tasks from 6am until late evening, completing a task list that my wife writes in a notebook awaiting my return. On Sunday, the morning is filled with less complicated work, leaving me relaxed for my afternoon flight back to Minnesota.

Well engineered, highly ergonomic workspaces make this level of commitment possible in Minnesota and Massachusetts. In 2019 I flew 400,000 miles to 40 countries, while also spending 3 hours a day driving around Boston in traffic. Comparatively, my 5 hour commute to Mayo on Sunday and Thursday is a respite.   

I'm a fan of a life that is constantly self-examined. At this point, I could not ask for a better workplace ecosystem that encourages accomplishment and engagement by design. 

Innovation at Home

This is the first of a two part series that describes where I live and where I work at Mayo Clinic.   

To me, life and work are inseparably intertwined.    You cannot have a productive work life if your home life is unstable.    You cannot have a balanced home life if your work life is unstable.    When I decided to work at Mayo, my wife and I agreed that we would live in Massachusetts running Unity Farm Sanctuary but I would work in Rochester/Jacksonville/Scottsdale Sunday night through Thursday night. 

Over the past month, I've organized a life in Minnesota, maximizing my well-being and efficiency.     I rented a 600 square foot apartment that is a 2 minute walk from Mayo Clinic.   I've moved those things from the farm that make the space uniquely mine - my morris chair, my desk, woodblock prints, green tea supplies, and a simple antique bed. 

Outside the window I can see the Mayo building and the Plummer building.   I'm near a great vegan restaurant and the local food coop.   I have a small stacked washer/dryer in the apartment.    Home Depot is 8 minutes away.   I purchased a used Subaru for airport commuting.

All of this means that I can arrive each Sunday night and drive myself from Minneapolis to Rochester.   Once in my apartment, I can create a simple dinner, write in my journal and prepare for the week ahead.   My bedroom is 10x10 - a perfect place to retreat and rest. 

Monday-Thursday I walk to work (and my workspace is the subject of the next blog) in the morning, spend the day with remarkable colleagues, then walk back to my apartment at night, stopping at the food coop to pick up fresh vegetables for dinner.

Thursday night I drive back to Minneapolis and fly to Boston, getting home about midnight. 

Just as with Unity Farm Sanctuary, I've turned my Minnesota apartment into an internet of things demonstration site.   I have a 100 megabit fiber connection to a Google mesh network.   I replaced the apartment thermostat with a Nest device that I can control remotely, keeping the apartment at 60F when I'm gone but adjusting it to 65F when I'm in town.  I've added smart plugs so that my morning routine turns on lights/music automatically while my evening routine prepares the space for sleep.   The locks are RFID controlled. 

The end result is that I have a stress free, highly functional environment around me when I'm not at the office.    I can cook, clean my clothes, write at my desk, review strategic plans in my chair, and sleep comfortably, all within the 600 square foot layout.    Pictures are attached below.   My many years collaborating with Japan have taught me well and my home space at Mayo is simple, spiritual, and supportive.

Thursday, January 30, 2020

Moving Complex Systems Toward a Goal

I recently told several of my Mayo colleagues that I'm an outsider who has landed in a new environment where the degree of collaboration, dialog, and friendly debate is amazing.    The following a kind of guest blog, started by Dr. Michael Joyner, who is also a writer 

He wrote to a number of us

"Great paper written by chairman of bank of England in middle of financial crisis.   Pertinent to anyone interested in nudging complex systems towards a goal."   

Below are the responses:

Let’s move away from risk prediction a bit and apply these concepts to our world.  The world of innovating and translating new solutions (hugely complex and risky) in the medical care industry (more complex and regulated than even the financial industry) to treat human disease (much of it psychological/societal/evolutionary) is off the charts with risk.

I love the statement of fighting complexity with simplicity – it intrinsically feels correct - so what should our heuristics be for advancing medical care?

Modern medical innovation is complex, perhaps too complex. Regulation of modern translation of medical innovation to products is complex, almost certainly too complex. That configuration spells trouble. As you do not fight fire with fire, you do not fight complexity
with complexity. Because complexity generates uncertainty, not risk, it requires a regulatory response plan to enable innovation and translation grounded in simplicity, not complexity.

 So what is our plan and our heuristics?  My suggestion to get us started in honor of Mr. Haldane:

1)    You must move out of the harbor and get in the race in order to win (win being to develop new solutions in medical care)

a.    The race has been underway for some time, so you are behind already, so get going and move with speed

b.    A race is the best analogy – we should move quickly in just about every respect.  “Fail quickly” is a trite but true statement

c.    How many things are stuck in endless cycles of planning or less than serious (not capitalized or staffed anywhere near the need) attempts?

 2)    Almost all of your strategies, plans, predictions will turn out to be incorrect along the way, no matter how much planning you do – you will assuredly have many failures as you progress - how you respond and your ability recalibrate course and keep progressing to the goal is all that matters in terms of achieving success

a.    The good news is at this point you are at least in the race

b.    As with the best entrepreneurs, if you have not failed at least a few times you should not be trusted with anything – very easy to say  and terribly hard to live it when you are deploying capital

c.    The art in all this is determining if the failure is due to execution, if it is then you have the wrong people and should switch out the team – or vision/goal, if it is then time to go back to the harbor.  The first determination (execution) is not too hard to make but hard to execute (needing to switch out the team).

d.    Extremely hard to determine if a group or individual that has failed should be cast aside or given new resources to try again – all of history teaches us that the best folks who we celebrate as geniuses failed many times before succeeding.  Of course, fools will fail as many times as you allow them.

e.    No easy answers here other than did the group or individual at least execute well and move with efficiency and speed, that is necessary component but not sufficient

3)    You should study the strategies and successes and failures of others, but because successes and failures are the result of an enormously complex environment with variables too numerous to count, we should not study them so much or lend them credence to an extent that we “over-fit” our analysis and plan. 

a.    Successes are tainted with survivorship bias – be careful when determining why and how they were successful

b.    Failures are often due to a lack of ability to recalibrate from the inevitable setback or a poor team in charge of executing than a mistake in vision/goal

4)    You will need capital sufficient to start and recalibrate at least twice

a.    Undercapitalization is a guaranteed route to total failure

b.    Perfect Oscar Wilde quote in the article.  We often know the price of everything (salaries and the cost of a team) but the value of nothing (if not a great team staffed as required then we will surely fail, so what are we tabulating)?

5)    The humans involved in the endeavor will override everything else – need to find and bet on the best team possible

a.    All of the above will be evaluated, capitalized, planned, recalibrated and executed by a team of humans – they will determine success or failure

b.    What makes life exciting and fun is that this means complexity and unpredictability – how do we find and support the right folks?  How do we determine that the inevitable failure is the result of the vision/plan or of the humans charged with executing it?  Can we hand additional resources to the team/individual who have failed twice already?  Bill Gates, Steve Jobs and Jeff Bezos, etc. failed many times – what did others see in them to continue to provide resources?

c.    Key question for us all is how to identify and recruit the right team – from the very top to the bottom – and hold all accountable for efficient and effective progress (not success)


The Manhattan Project is a great example of survivorship bias – we celebrate it (in a way) because it was successful.  However, that does not mean that throwing $22B and a lot of really smart people at an objective means you will succeed.  Indeed, that approach has failed more often.  It is in the intangibles – I would argue that the sheer pressure that it must succeed (because of the fear of what if we lost that race) meant the accountability and demand for speed was very large – folks got out of the harbor and recalibrated at high speed (or so I imagine).   Pretty hard to re-create that environment – hence the Haldane teaching that it is dangerous to extrapolate characteristics in a complex world


The keys to success when moving complex systems toward a goal are:

1) Engineering problem, not a theory problem.

2) Clear definition of success.

3) Response to a real existential threat.

4) One customer.

Much of what we propose as innovation does not clearly meet any of these criteria.  Manhattan and Apollo did.  The Transcontinental railroad is another example that meets several or all of these characteristics.


And that's what a group of wonderful colleagues debated on a Sunday morning.

Wednesday, January 22, 2020

Advice for Aspiring CMIOs

Recently, my colleague Steve Peters, chief medical information officer, Mayo Clinic, and I discussed our life experiences as CMIOs.  We talked about how the role has evolved along with changing technology and the transition to nearly universal adoption of electronic health records by large health centers.

 I asked Steve to share his insights on 'what makes a great CMIO in 2020' and captured his thoughts for you.

"I have thought about the 'post-EHR' CMIO as most large centers and hospitals have moved on from the initial implementation.    Here are a few thoughts:

1.       Serves as the primary physician champion for all major clinical information technology projects, including EHR implementation and information security.

2.       Assists in development of IT strategy and planning.

3.       Acts as an advocate for protection of patient privacy and the security of protected health information.

4.       Supports various regulatory compliance activities including HIPAA, Meaningful Use, and billing compliance.

5.       Represents the medical community and serves as an advocate in the promoting the use of information technology in the clinical setting.

6.       Partners with leaders in the effective adoption of information technology solutions in support of clinical care, research and education.

7.       Serves as a physician champion in the development of the electronic medical record and practice management tools.

8.       Maintains an awareness of existing and emerging technology, regulatory, and market factors that have an impact on healthcare information management.

9.       Accountable for the identification, development and execution of education, training programs, and services in the area of computer skills and competencies in the use of electronic tools for patient care, quality, resource management, and performance improvement.

10.  Going back to the 'grandfather' informatics board preparation, I found some broad texts like Biomedical Informatics (Shortliffe and Cimino) very valuable, especially for those areas in which I have less experience or expertise.   The major meetings including HIMSS (from the industry standpoint) and AMIA (more academic) are valuable.    Many areas have regional CMIO meetings to share ideas.   And read blogs."

Tuesday, January 21, 2020

A New Model for Sharing Insights While Protecting Privacy

Last week at JP Morgan, Mayo Clinic announced a new collaboration with nference that I would describe as "Cloud-hosted, de-identified, federated learning in which the tools are brought to the data instead of sending data to the tools"

 This Healthleaders article describes it well.

 Here's a broad overview.  Let's start with 3 containers.

 The first container is controlled by Mayo Clinic, holds identified data, and has one purpose - the development and optimization of de-identification algorithms. Selected data scientists, who are accountable to Mayo Clinic, are asked to help with algorithms via time limited, audited access to the container.   They are either Mayo staff or collaborators from outside who are trained in Mayo policies and held accountable to the same requirements as Mayo employees.    No data ever leaves this container.

 The second container is a controlled by Mayo Clinic, holds identified data, and has one purpose - running the perfected de-identification algorithms and producing a de-identified data set. That de-identified data set is moved to the third container.

 The third container is for running innovative applications brought to Mayo by partners offering unique analytics on the de-identified data. No data leaves this container, the applications are brought into it. A joint tenancy model enables the container to be run by Mayo Clinic but others to be given limited, audited use of the container to run their applications. The only thing that ever exits the container are data insights or knowledge. For example, if nference is asked a question about drug discovery, its machine learning/natural language processing software in the container can pose the question. The answer is shared but not the data used to generate the answer.

To me, this is the perfect balance of agility, innovation, and privacy protection. I've worked in many organizations and not experienced a design that has so many safeguards against  data leakage. 

We'll populate the third container with our first wave of de-identified data later this year.  I'll continue to report on our progress.

Thursday, January 16, 2020

Dispatch from JP Morgan

 Although I've been attending healthcare and technology conferences for more than 40 years (yes, I attended Comdex in 1979), but until this week had never attended the JP Morgan Healthcare Conference.  The conference gathers 60,000 investors, innovators, and providers for four days to plan the next year’s path for healthcare and building relationships that will foster future innovation. I have extensive experience attending HIMSS , which has similar numbers, but only a small fraction actually attend the main the JP Morgan Healthcare Conference.  

My Mayo colleagues and I presented formally in the non-profit track but the remainder of the meetings was dedicated to side conferences in numerous hotels, restaurants, galleries, and office towers.  I'm a practical traveler who walks to most meetings but there was no way to attend 40+ meetings in 30+ locations without help. I had an amazing driver who took me to a different meeting every 30 minutes, adeptly navigating a sea of activity.

Was it worthwhile? What it consistent with my role and mission?

Yes, it was one of the most productive conferences I've attended.

In one city in one sprint of activity, I was able to meet with strategic partners, collaborators, innovators, the press, and stakeholders. I was able to have discussions about complex, technological, challenging, and controversial ideas while reading the emotion of others in the room. I was able to create new friendships and rekindle old acquaintances.  

I've often said that digital health progress depends upon technology, policy and psychology. People ask how I think about contracts and legal agreements for partnerships and collaborations. Although 100+ page documents with appropriate protections are essential, my great hope is that trust and friendships are built so that contracts are signed and never referenced again. Events like JP Morgan are foundational to that kind of relationship building.

Press communications at such events are convenient and productive. If we're going to change the world of health, we need to broadly explain what we're doing, why we're doing it, and how we're putting patients first. All major press outlets are well represented at the conference and were able to talk. I was pleased by the press coverage of the Mayo presentations

Finally, JP Morgan enables internal teams to bond and as we divide up the stakeholder meetings, each using our skills and expertise to greatest effect. From 6am to midnight each day we did our best to move our innovation agenda forward.

I remain energized by the optimism of the conference.