In this podcast, we talk with Dr. Maulin Shah, Chief Informatics Engineer for Providence St. Joseph Health (PSJH) about his journey from implementor of electronic health records (EHRs) to Health IT innovator. Like many of his peers, Dr. Shah was deeply involved in the implementation and subsequent optimizations of EHRs over the last decade. His shares with us how a combination of clinical, operational and engineering expertise combined with his energetic approach lead him towards a more entrepreneurial and innovative focus in his work. Dr. Shah’s views of where health IT has been and where it is going provide valuable insights that can guide future strategic planning.
Given his depth of experience and his innate passion, you can bet his pet-peeve is a good one and his advice to “remember your roots” is sage indeed.
Dr. Dave Levin: Welcome to 4x4 Health, sponsored by Sansoro Health. Sansoro Health, integration at the speed of innovation, check them out at www.Sansorohealth.com. I’m your host Dr. Dave Levin. Today I’m talking with Dr. Maulin Shah, Chief Informatics Engineer for Providence St. Joseph Health, and the second largest non-profit health system in America. At providence St. Joe he focuses on maximizing the value of their EHR through optimization and innovation. He previously served as medical director for the epic implementation project across 26 hospitals and 400 clinics. In my experience Maulin is always a pioneer, always ahead of the curve, I can attest that he’s a smart guy who can often see around the next two corners and know how to get things done. Welcome to 4x4 health Maulin.
Dr. Maulin: Thank you, thanks for having me.
Dr. Dave Levin: You bet, let’s get started. I’m going to ask you a series of four questions; you have up to four minutes to answer each one, so let’s get into it. Question one; tell us about yourself and your organization.
Dr. Maulin: Yes thanks, I think you flattered me with that bio, so I am as you said position infomaticist and my current role is with chief informatics engineer at providence St. Joseph. I went to work on all the fun stuff, so providence St. Joseph health as I just mentioned it’s one of the largest, not-for-profit health systems in the country, we have the largest single instance occurrence of epic out there so we got now more than forty hospitals and we’ve got a thousand clinics and that has given us some unique challenges and some unique opportunities and I’ve kind of found myself squarely in the middle of those. When I initially started as the medical director of the rollout, we were busy trying to figure out how do you convince 20,000 physicians to do something different, so we built our system informatics program, our physician informatics program from the ground up and we matured that over the years, then kind of transitioned into taking on the optimization responsibilities for the tools. So figuring out what the right work was to do and then how to implement those changes into our tools to kind of get the best clinical outcomes, so really partnering with our clinical leaders and figuring out the key initiatives that we wanted to send down the pipeline through epic. Most recently I’ve kind of transitioned again in the last couple years and now I’m focused more on innovation and kind of the bleeding edge of what we can do with our EHR, so more than just keeping the lights on and more than just potentially building alerts or clinical pathways, really starting to think outside the box of how we can leverage this technology both in terms of patient engagement as well as improving provider satisfaction, burnout and those kind of things. So really been looking at different ways to innovate kind of all still in and around the space of EHR, but also kind of outside of that to really leverage this huge data asset we have.
Dr. Dave Levin: That’s such an interesting pattern, I’ve seen a number of our colleagues begin their journey with implementation and optimization and then they seem to migrate into different kinds of roles. I recently talked with a colleague and we talked about folks that migrated to the bridge of the ship, they take more of a strategic kind of role, folks that migrate down into the engine room who continue to take a deeper and deeper tactical role. And then there’s this kind of funny in-between in a way that’s around innovation, what drew you to that, what why did you personally decide to move in that direction?
Dr. Maulin: I think there’s a lot of reasons, I think at a personal level you’re always trying to challenge yourself with the next thing and even though we were doing just incredibly innovative things in our routine optimization program, our model of optimization had become routine which is great news for Providence and St. Joseph is that we had gotten optimization to some degree down to a science how we intake a problem, how we understand a problem, how we specify the solution, how we use all the different tools within epic to solve that particular problem. All of it became a standard process and we were able to get to the point of rinse lather repeat, and that was a great thing and really was our whole goal was to be able to expand that capability from beyond a small sort of group of cognizant thinking you had to do it and to really to allow anyone who could get trained up on how to do this kind of optimization process in the EHR.
So once we got it to that point my creativity, actually that doesn’t get packed as much right I mean you get some creativity, the actual project work but you’re not architecting anything, you’re just kind of doing the same thing with a different clinical problem which can be interesting for a while, but for me I’m a biomedical engineered background I’ve only been wanting to kind of invent new things, I’m a creator not a person who pushes things along once they’re already out. So that I think was the main thing for me was that I wanted to switch back to a mode of being able to innovate and be creative, kind of at a larger scale than just project my project.
Dr. Dave Levin: Well let’s be honest I think you and I share a couple of traits, we both get energized by new things, new opportunities as you said the creative aspect, and you said something else that I think is very interesting in another pattern it seems like we also divide along the lines of those who like to start things, kind of the messy beginning and those who like and excel at sort of stabilizing and maintaining and shepherding, they’re both I’m sure you’d agree really incredible and important roles but they’re also very different.
Dr. Maulin: Yes absolutely and scaling something is a different skill set. Scaling something from a small group to being able to have anyone do it’s talking about starting to add process and starting to add steps and reliability and those kind of things, which are all super important and all just made my eyes glaze over. I like to build stuff, I like to start things out, get them to a point where they can scale, where we know that they can scale with just some more elbow grease. Like we know this is going to work we just need to execute now the point that I start to kind of just transition my role a little bit and that’s where that scene in these points. So when we did our rollouts, and honestly after doing a dozen hospital that was rinse lather repeat and so that was about the time that I transitioned into optimization career, just started optimization and then we did that for three or four years and now that kind of pretty rote and so now I’m moving to this innovations base. Which also keeps me a little bit more focused on that creative and that front end of the problem, because really my role right now isn’t to take something to scale, it’s to really try out a lot of stuff and see what’s stick and then the ones that stick try to find the right team to be able to take it to scale if that make sense.
Dr. Dave Levin: So you just gave me a great opening for the next question, what’s the most important or interesting thing you’re working on right now?
Dr. Maulin: We’re working on a lot of really interesting things right now, it’s like three kind of primary things that are really keeping me busy most of the time, I don’t know if you’re allowed to have three primary things but…
Dr. Dave Levin: I asked you for one and I fully expected that you would give me more than one, no idea so you go right ahead.
Dr. Maulin: Yes, so in our digital innovation pillar at Providence we’ve been working on incubating several different ideas and companies and one of the companies that we recently spun out that was incubated inside of Providence is a company by the name of Xealth and we can provide a hyperlink to that for your listeners. But Xealth is a really fascinating group, these guys are serial entrepreneurs who have worked in other industries and been just incredibly successful and they wanted to come in and see what they could do in healthcare. So they came in and they worked at Providence for a couple years, really it became part of the culture here and started to understand where our opportunities lie for the future and sort of came up with some ideas. And so the platform that they’ve created is one for bringing the patient engagement digitization workflow into the physician workflow, into the clinical workflow, so what do I mean by that? Well there are so many apps and services out there for patients right now, it’s the Wild Wild West, I mean whether it’s your Fitbit and your Apple health all the way through diabetes management, obesity management, hypertension management, smoking sensation there’s an app for that, for everything. The problem is nobody knows what’s good and what’s bad; nobody knows how to separate the wheat from chaff. And when you’re a major enterprise like Providence St. Joseph what are you going to put your weight behind, what do you want every one of your patients to get or what are the top two or three things like every diabetics should get this after this other thing. So the Xealth has built a platform to allow enterprises to really curate a formulary of digital services that can be prescribed directly through epic to the patient’s, so that for example if a patient is overweight I may prescribe them Weight Watchers and I do that directly in my epic interface and they automatically get an email from weight watchers with a pre-registered account and all sorts of other things. So we’re connecting both the clinical workflows of the enterprise with the app vendors and connecting those as data to connect them to the patient and really get the best outcomes. Meanwhile it’s a full round trip where if the patient subscribes to the service that I recommended the physician, I can now see how they’re doing right within my epic interface, I can see if they’re going through a meeting for example or see what their progress is. So it’s a really interesting company that’s now starting to deploy more and more widely that we piloted it at problems and I get to spend some time really thinking through what are the key use cases to that.
Dr. Dave Levin: I have the benefit of having expensive time working with you guys at Providence and with the innovations team and know the Xealth team and couldn’t agree more with your observations. I think I see a second podcast in our future where we could just talk about this life of innovation and some of those aspects of it as well, very cool stuff. I want to take you to question three and before I do that I want to remind you Maulin this is a family show, but what I’d like to hear now is what’s your pet peeve or your favorite rant these days?
Dr. Maulin: It’s all about usability, for me the grand missed opportunity of the EHR was to make the EHR about health, even though it’s called the electronic health record it really isn’t about health, it’s not about the patients’ health and it’s really not about the providers or the clinician’s health. I think that our major vendors like Epic and Cerner and others are starting to understand the problem and starting to think about usability more, but for me day after day I’m watching physicians and clinicians nurses just be more and more burned out by how onerous Bede’s tools that they have to use are.
And figuring out a way to get them the right information at the right time, to cut out stuff they don’t need, to not be alerting them all the time, to make the right thing easy to do, to make the wrong thing hard to do and to really make them feel like they’re being supported by their record is really my goal in life. I mean that’s what I really see as be the epitome of success and being able to have these tools in service to patients and then in service their to the caregivers and the clinicians around them, as opposed to the other way around. But you know as much as we get I’d say some lip service or attention, a little bit of attention here and there from the major vendors about usability just as they’re saying that they’ll release something else that just makes your life even more complicated.
Dr. Dave Levin: Keep it PG now but go ahead.
Dr. Maulin: So epic in particular has a usability program that they’ve just launched and that usability program you can teach customers how to build more usable solutions within their framework great idea, beautiful presentation, the only problem is that internally they don’t listen to their own, what their preaching. And so I can point out examples in every single app within epic where they’ve violated their own principles and this isn’t just legacy stuff that they haven’t fixed, this is new stuff coming out and saying well you just said we need to do it this way and you did it that way, you’re building solutions that you’re admitting you know are not usable because you’re violating your own principles.
Dr. Dave Levin: Do you think that’s true we don’t want to just click on them; I mean my absolution is it’s true across most if not all of the current generation of the EHR?
Dr. Maulin: Absolutely, and to be honest what really kills me in this new space of sort of app vendors it’s not all that much better, like they are far more usable because they can be nimble, they’re solving smaller problems to be honest. Most of these app vendors are solving smaller problems but obviously usability in a clinical setting is not the same as usability on your phone when you’re reading something or usability in a bank.
It’s just a different thing and the sooner that we can get ahold of the fact that clinical workflows aren’t like everything else, don’t try to fit us into something else but actually sit down and think about the clinical workflow itself and then design a solution as opposed to saying hey I have this cool widget, let’s see if we can make it work in a clinical situation, you’re going to get to some actual stuff, which there’s some stuff out there but it’s few and far between.
Dr. Dave Levin: Yes very interesting and I think astute observation about the emerging apps, I personally have a lot of hope for where that’s going and I’m curious if you see what I see. I mean I listen to what you have to say about self and what they’re doing and I can imagine a similar kind of plug-and-play app model for providers, are we headed back to a kind of best-of-breed in the future?
Dr. Maulin: I think that’s fascinating, I think that is super fascinating so they came out with an article this week that I’m sure you’re aware of, sort of all the buzz right now about why doctors hit their computers as a New Yorker, actually fantastic read again we should provide a link for your listeners if they haven’t seen it. But there is just an amazing synthesis at the end about how what we need to be thinking about is essentially an app based world, where based on your cynical role, the institution you’re in and what you’re doing you might be able to download various different apps that color your experience both in the EHR and outside EHR. And it’s actually a really interesting idea it’s one that we’ve been really tossing around here at Providence now for over a year also speaking about how do we empower our clinicians again. So really the top-down nature of the EHR has been great to tame the Wild Wild West with a tool called it was, he used a biological analogies where he said we use to have mutation all the time where everyone could use their own workloads, there was no selection pressure so there is no selection of the best ones and then we got all these EHRs and now we have all selection and no mutation, there’s no variability that allows for finding best practices. And so what apps could do and what I’m really excited about is the opportunity for introducing variation in a way that allows for natural selection to pick the best breed and really getting to the whole picture and that’s what we’re talking about on Sundays, it was a great article.
Dr. Dave Levin: Well I’m all in on that I’m a big believer in market forces and competition or part of the answer to the sort of innovation constipation we have right now, and I’m all-in personally because I’ve spent the last four or five years working with a company that’s focused on integration and our operability because they believe that that’s an enabling technology that that’s a fundamental building block in the kind of app economy you’re describing. And likewise to me this is sort of interesting parallel with personalized medicine, you know typically when we talk about personalized medicine we’re talking about people’s molecules or maybe for being really fancy where their personal tastes and preferences, I think this extends to IT as well in that where we need to end up is personalized health IT as well for patients and providers. And we’ll know it when we see it because the technology will have essentially receded into the background, so that instead of looking at the technology we’re just doing our work. We’re a long way from that but I see all kinds of evidence in nature in other industries that it can be done.
Dr. Maulin: Frankly I get to see a lot of examples in our industry of small companies that have some great ideas that could you don’t know which ones going to be the one, you look at that now like you know that might be the one that might be a paradigm shifter, that really gets us to that world where you have engaged and empowered clinicians, you can customize their experience and yet not very care, I mean like I guess special Holy Grail.
Dr. Dave Levin: Yes I couldn’t agree more. It’s funny I was quoted in an article recently as saying something like, we don’t need another crappy hard to use first-generation EHR and apparently that was a controversial statement, I thought everybody already believed that. Now I wouldn’t really single out any particular EHR, I know you spend a lot of time on that particular one, my experience is this is endemic in the industry, it’s just human factors and user interface design, it’s just not in the DNA of these companies it’s not how they grew up. The dilemma is a lot of the companies that have that don’t understand healthcare and I would argue that’s why companies like Xealth and the process you described at Providence St. Joe are intriguing maybe that’s how the mash-up will occur. But as I said I also know it’s not as simple as that, we could probably devote a whole show to that topic. Let’s wrap up and Maulin take us home by giving us your most sage advice.
Dr. Maulin: Well I save it never forgetting your roots is an important thing no matter who you are and where you are, and in informatics and in my career it means not forgetting what it’s like to be a practicing physician on the line, taking care of a second crashing patient in the ICU, knowing what the stresses are really like and staying clinically relevant, I quit my practice about two years ago because I just couldn’t keep doing both. But staying in the hospital, staying in the clinic, staying on the side of our clinicians so that we’re in their service, we’re the service of our patients, we’re in the service of our clinicians and not forgetting that and kind of getting lost in technology or getting lost in some grand scheme of patient quality improvement that doesn’t have any basis in reality is to curb it all.
Dr. Dave Levin: Well I think that’s beautiful, if I could build on that I would add remember what it’s like to be a patient or to have a love right as a patient as well. And like you I think it provides the mission and the work and it provides grounding as you make what are often very difficult decisions where there’s no clear right answer, and I have also found that for my IT colleagues it really helps to connect them to the meaning and importance of their work as well, so I think that’s wonderfully sage advice. Maulin this has been a terrific conversation I really appreciate your candor and your insights, like I said you’re a guy that can often see around the next two corners and I think you gave us a bit of a view into what is around those corners, so thanks so much for being with us today.
Dr. Maulin: Yes, thanks a lot for having me, any time maybe we’ll have that follow up show sometime.
Dr. Dave Levin: I think we should. You’ve been listening to 4x4 Health sponsored by Sansoro Health. Sansoro Health, Integration at the Speed of Innovation, check them out at www.SansoroHealth.com I hope you’ll join us next time for another 4x4 discussion with healthcare innovators, until then I’m your hoist Dr. Dave Levin, thanks for listening.