Datica Podcast

October 22, 2019

International Health IT

In this episode of 4x4 Health we learn about international health from Dr. Manish Kohli, who has a rich background in international health and technology. Dr. Kohli shares about his experience as CMIO in Abu Dhabi and offers insights on how to use technology to improve access and quality of care and patient experience.


Dr. Dave Levin: Welcome to 4x4 Health sponsored by Datica. Datica; Bringing health care to the cloud. Check them out at www.datica.com. I'm your host Dr. Dave Levin. 

When it comes to innovating the U.S. health care system it's often useful to look at other industries for ideas and trends. But what about health care systems outside the US? What insights can be gained by examining countries with different cultures, technologies, resources and practices. Can their health care challenges and solutions provide inspiration and understanding for addressing our own? Today on 4x4 health we zoom out for an international perspective. With Dr. Manish Kohli. A global physician leader working to transform health care and promote well-being around the world. Dr. Kohli has extensive experience in international health care settings with a particular focus on the use of health information technology to achieve expanded access and better quality. Manishs' career as both diverse and impressive. He was the first CMIO in the Middle East North Africa while at Cleveland Clinic at Abu Dhabi and helped establish the first, fully digital, HIMSS stage 7 hospital in that region. At partners Harvard Medical International he was director of Global Programs filling the roles of CMIO of University Hospital and head medical informatics for Dubai Healthcare City. Currently Dr. Kohli is chairman of the global board of directors for HIMSS, the Health Information and Management Systems Society and international not for profit organization focused on better health information and technology. He's also president and CEO Manish Kohli M.D. advisory and consulting services and a co-founder and partner at infinite care holdings. Reflecting his thoughtful well-rounded nature Manish is the founding editor of SCOPE, the literary and fine arts magazine of SIU School of Medicine, now in its 26 edition. And a speaker who has lectured extensively throughout Asia, the Middle East, U.S, Europe and Australia. He's also a dear friend and colleague who I got to know well when we worked together at Cleveland Clinic and Cleveland Clinic Abu Dhabi. And when we traveled together in India, perhaps that's a subject for a future podcast. Manish’s dedication, humanity, empathy and passion for health care and key innovation have been inspiring me for years. I expect our listeners will be inspired as well. Welcome to 4x4 health Manish.

Dr. Kohli: Thank you Dave and thank you for that kind introduction.

Dr. Dave Levin: Well let's get right into this. I'm going to ask you a series of four questions today and we'll take about four minutes to discuss each one. To begin with tell us a bit more about yourself and some of the organizations you work with.

Dr. Kohli: Well Dave I'm basically a doc at heart and had been extremely privileged to be part of some really exciting endeavors, not only in the U.S. but globally. I trained in Chicago at Rush Presbyterian St. Luke's and that was sort of the beginnings of getting involved in system redesign as I was the chief resident of the program. And my first initiative was really looking at how do you improve patient satisfaction back in the paper world and the obvious answer was gee technology is missing. And as you looked around all other industries were ahead of us. So the glorious moments of chief residency was when we were given a Palm Pilot as a reward for being chief resident. So we went and survey it and studied and made the recommendation that we need some kind of technology in the residency program. Following that I had the good fortune of joining Johns Hopkins School of public health in the preventive medicine program and that really was the turning point I would say in my career where I had a fabulous opportunity to work with the Rockefeller Foundation in India looking at how we use technology to improve access and quality of care and patient experience. Also I had a chance to work with some insurance companies as well as some consumer driven health plans and really getting an insight on how technology is being used in healthcare back in the early days. That led to being named the CMIO for Johns Hopkins community physician, the outpatient arm of Johns Hopkins where I was asked to lead a clinical transformation initiative. Essentially we had decided to go fully digital and back in the early 2000s the entire organization from largely paper based environment to a fully digital electronic fully functioning electronic medical record. Including data conversion between two disparate vendors, which was unheard of in the early 2000s. The reality was that there was not a plug and play solution as it's available now. We had to innovate and invent and get that done, because the CEO said Manish you have to get it done. Subsequently once we finished the project successfully five months ahead of schedule, I had the good fortune of being asked to serve as CMIO of University Hospital and a medical director and (Inaudible) healthcare city or the free zone that had been set up in collaboration with partners international. And that experience was absolutely amazing where you on top broadening your scope from serving as a CMIO leading digital transformation and health system, I was asked to sort of work with 77 disparate healthcare institutions in the way healthcare city and helped set up a health information exchange that when I left was collecting data on 400,000 patients. This was around 2008 and 2009 when the financial markets had run into some turbulence and as a result that initiative lost some momentum. As we were preparing to transition out of that initiative I received the invitation from Cleveland Clinic to serve as the first physician and first CMIO to help build a brand new hospital like in the center in the Middle East. And that was absolutely a life changing experience for me, where not only were we going live with a large electronic medical record, we have 76 other clinical and non-clinical systems that would go live at the time of the hospital activation. We had a brand new building which has more steel than the tallest building in the world and by the way we had 3,500 or so new individuals who had never really worked together coming together to deliver not just a hospital, but Cleveland Clinic level of care in the Middle East. And I felt so fortunate to collaborate with so many bright individuals, including you Dave as the CMIO of Cleveland Clinic at the time. Where we were able to actually dissect and take the best of Cleveland Clinic and digitally enable it for this new facility.

Dr. Dave Levin: There's a lot in there but we should I want to go back and unpack some of this and we're going to go deep on CCAD. But there's two things in there that sort of struck me. The first is I’ve often joked that if my roles as CMIO try to get things done that I was often trying to broker peace in the Middle East and in fact you sat in the Middle East and as you described brokered an arrangement where over 70 different entities came together to share information in new ways both culturally and also technically. I want to hear a little bit more about that. And then my other is just the observation of you started with a Palm Pilot and residency and by the end of your story there you're at Cleveland Clinic Abu Dhabi, one of the most advanced health care facilities both technologically and otherwise in the world. So it's been quite a journey for you Manish.

Dr. Kohli: Absolutely and I’ve almost felt like a little kid in a candy store, where I’ve been part of an ecosystem that have been really really top performing and have a chance to do some of these really really cool and innovative things. Oftentimes first at that time. 

Dr. Dave Levin: There's two things here I'd like to drill a little deeper into. The first is really some of the differences in general that you've observed and hopefully some lessons that you've drawn from that, about implementing technology in other countries, about delivering health care to other countries. And then I really would like to come back to this issue of the challenge of delivering as you said Cleveland Clinic level and style of care in a different part of the world. But first the sort of general lessons and I want to share a personal experience here. I remember very clearly one of my first trips to Abu Dhabi and you were showing me the ropes and getting me oriented and you took me to a meeting and I'd listen to the conversation and it just didn't make any sense to me and I'm thinking, yeah I must be jet lagged. I don't understand this. And you finally leaned over to me and said, Oh yeah you must be confused because you don't know there's no street addresses in this town and there's no ambulance service. And so all of a sudden the discussions about how do you get results to people or how do you get sick people to the hospital, they just take a completely different turn. I'm real interested in some of those general observations of what you've learned from working in these different environments. And then indeed perhaps some lessons that you think are more universal.

Dr. Kohli: Absolutely Dave as I’ve traveled to different parts of the world and talk to different leaders and health systems one thing is pretty clear, that everybody is challenged with the five fundamental issues. Quality of care, access to care, cost of care, clinician burnout and patient experience. In my observations no one health system has fully cracked the code and I think that's where the beauty of international work lies. You know where we can actually learn from each other and this is where I’ve been truly privileged to be a part of HIMSS as part of Asia Pacific governing council and then the HIMSS global board and then subsequently the chair of the global board. Some of the work that HIMSS is doing is absolutely amazing in terms of cross pollinating some of these practices and bringing some of the best of the US globally and now bringing some of the best global practices back stateside. But couple examples stand out and I think this is where the complexity of healthcare system, but also important leadership stands out. So I was in Denmark recently and learned that the government there has mandated a 20 percent reduction in hospital meds. You think about the implications of that kind of a policy change. It is galvanized to catalyzing a shift from hospital based care to primary care settings to home based care to telehealth. And change is hard and you may talk to the leaders in the front lines that they are trying to figure out how do we actually make this happen. What happens when we lose 20 percent of our beds. But these are the kind of drivers that are needed where the policy makers say this is the direction we want to go in. The cost of care is getting too high. How do we actually rein it in. How do we leverage newer models of care to do what's right for the patients at a lower cost. Singapore is another example where at the city state level they have decided that they want to have an integrated health record and they've been taking measured depth over the years to really achieve that goal. Now granted both of those examples of countries that are relatively small. But I think there are lessons that we can learn from those types of experiences and apply them to North America to Asia and the rest of the world. 

Dr. Dave Levin: Those are great examples. The other thing that I was thinking about was spending, I spent some time in China as you know and what's fascinating there and in many other countries around the world is they more or less skipped over the desktop revolution and went right to mobile. And you look at statistics for the number of mobile devices per citizen and they're just astonishing. And to me this is an example of where we actually could be looking at our from the US perspective, looking at the future a little bit of well okay, how are these health systems and these societies leveraging this fully mobile approach whereas what I would argue we're still kind of in the transition from desktop to mobile. Is that a reasonable example as well as some of the differences you see? 

Dr. Kohli: You are spot on. I think what happens to telecommunications 20 years ago where developing countries went from land based infrastructure to mobile infrastructure. I see something similar happening now where developing country are skipping over and actually bringing in some pretty cool solutions to the patients and to healthcare, The power of mobile and China, India, I mean I have demonstrated that. I mean China, I was at a hospital there recently and they are actually integrating their equivalent of WhatsApp into the healthcare space to improve registration, scheduling and billing. So we have some really innovative models out there that these countries are developing. And my sense is the pressure, the cost of technology are going to drive some of the innovative solutions in countries like India and China and Southeast Asia and Africa.

Dr. Dave Levin: I want to return now to the other point you made earlier about the work you did with Cleveland Clinic in the construction of Cleveland Clinic Abu Dhabi and my understanding was this was conceived as, this was not just going to be a state of the art facility. But this was going to be a place where we could really begin to figure out how do you deliver Westernized state of the art clinical care in these different kinds of environments. As you said, bringing Cleveland Clinic style medicine to the Middle East. Tell us a little bit more about the vision for that and some of the practical considerations.

Dr. Kohli: Yeah. One of the things that really impressed me is really at the highest levels of leadership in Abu Dhabi, His Highness Sheikh Mohammed of Abu Dhabi, Toby Cosgrove, the former CEO of Cleveland Clinic. I mean for them to forge that partnership and really say we want to make a difference and really catalyze a change in the healthcare ecosystem, that is called visionary leadership. And I must say that these two leaders, then put forth the mandate that we all had to live up to saying that don't just build another hospital, because many people have done that. We really want the Cleveland Clinic in Abu Dhabi. And what that meant at the day that we opened, we have to deliver the same level of care that one would expect back in Ohio or Florida or in Las Vegas. And that is no small feat 7000 miles away with the cultural considerations, with workforce challenges and just the whole cultural transformation piece.

Dr. Dave Levin: Well that's true. In addition you have to do that in a way that's culturally sensitive and respects local norms. And there's all these sort of interesting kinds of adaptations that bottom vacations and things that you have to deal with as well. Pick one or two examples and walk us through some of the interesting challenge to how those were addressed.

Dr. Kohli: Sure sure. So I’ll talk about a challenge and a success story right. The first is how do you actually go about delivering Cleveland Clinic level of care on an opening day. You know when you have all these moving parts, a really big building, state of the art building. Some would say that it's a hospital combined with a five-star hotel come with a fully digital lab. You have people from all over the world who would be practicing medicine, taking care of patients there. We had doctors from Western Europe and North America, US, Canada. Nurses from Philippines, India, Australia, Ireland, England, US and then supporting our workforce from a vast array of countries. So we learn that we have an opportunity to (A) learn from the best. Cleveland Clinic has been a leader in digital technologies for many years. Early adopter of electronic medical records and there was a treasure of lessons from a technology perspective that we wanted to bring over. And not only that, Cleveland Clinic is also known for the highest level of clinical care. And what we wanted to do was really ensure that those lessons and those practices were available to our team in Abu Dhabi on opening day. And as we thought about how do we do so, Technology was the backbone. Now I jokingly chide when an EMR goes live, the EMR is the blue eyed baby because everybody sort of is focused on EMR go live. But when we activated and open the hospital, EMR was supposed to be the stabilizing influence because everything else was moving around it. And one of the things we did was for example, the care of the stroke patient. What we decided was that we would emulate what Cleveland Clinic were doing for stroke care and actually digitally enable it in our EMR and trained the entire workforce so would touch a stroke patient on the best way to take care of a stroke patient. So the care guide that had defined best practices in stroke care and the stroke pathway that Cleveland Clinic technology team had developed and embedded in the EMR. We took it, we regionalized it and we built it into the EMR and trained everybody on that. The result of that was within a year of opening we were named the stroke center for Abu Dhabi.  Now that is I would say a recognition at the highest level. But not only are you providing care but you're recognized you are providing the best care in the middle of Abu Dhabi. And that would not have happened by the countless individuals who had worked over the years on the care for the stroke patient and the technology teams that had only proven success and the team in Abu Dhabi that was able to actually regionalized it and actually build and execute on the best practice. So that's one example where we looked at the challenges and we use technology to bridge that divide.

Dr. Dave Levin: That's a terrific example. And you and I have talked about this before in Cleveland Clinic Abu Dhabi. It's hard to imagine a more green field of green field. Literally there was nothing. So it was both for design and creation of facility, the figuring out the staffing model, the approach to care, all the supporting technology. It really all was assembled out of thin air over a period of year. So truly remarkable.

Dr. Kohli: Yeah. And then I tell you Dave the biggest delight of that initiative was the great people. Talk about being in a startup environment and working with some incredibly talented and passionate individuals on both sides of the ocean. I could not have asked for anything better. And I have such fond memories of that entire experience.

Dr. Dave Levin: Well I can second that from the little bit of time that I was able to work with you guys. It was inspiring and life changing experience for sure. If you've just joined us you're listening to 4x4 health and we're talking with Dr. Manish Kohli, chairman of the global board of directors for HIMSS and president and CEO of Manish Kohli MD advisory and consulting services. So Manish you got your hands on a lot of different things these days. What's the most important or interesting thing that you're working on right now?

Dr. Kohli: The two area that are really close to my heart are access to care and this whole phenomenon of burnout. I see that those two are intricately related and I’ll get back to that in a second. But there's a personal reason behind this. You know I have family in the U.S. and other parts of the world. And I’ve had some pretty eye opening experience that I should say and helping my folks get care overseas and realizing how scary the experience can be when you're not in a familiar surrounding and when you don't have access to the things you take for granted in the US. I also ended up actually having my surgery in the hospital I helped build. So for me it's really as a patient who could be anywhere in the world. My personal belief now is that what can we do to ensure that every human being has access to the best level of care possible when they need it. We have a lot of work to do to get there. But I think with the tools of technology that are available and with the drivers that exist in the macro environment, I think we are closer to it than few years ago. A couple of things that I'm working on is I am actually on the board of a non-profit organization called Wings of Hope, which has actually been nominated for the Nobel Peace Prize twice. And essentially this organization leveraging the power of aviation to improve health care and health access. Based in St. Lewis and essentially to provide free flights to patients who need it, but they also have presence in several other countries in South America and Asia helping advance healthcare and access to healthcare patients who need it. And I find tremendous synergy and alignment and what the organization is doing and how we can actually expand that mission to more countries. We are talking about marrying drone technology and potentially telehealth and to see how we can actually create and make a measurable difference in health and health outcomes for the developing world. I'm also on the standards advisory panel for joint commission international and we are working on where we actually write standards that are used internationally and we have started to look at how do we actually improving access to care, quality of care and also the workforce challenges and burnout. At HIMSS as well we are looking at clinician and staff burnout and how HIMSS as an  organization can actually help advance that so that we create a much better end user experience and subsequently patient experience globally.

Dr. Dave Levin: A lot in there as well. I definitely want to go a little deeper on this burnout resilience question. Let me just echo your enthusiasm and your hope around the opportunities to expand access to care. And it's both in some of the new care models and economic models and but also as you rightly point out, there's a host of technologies now that we have an opportunity to deploy and really creative and flexible ways to virtualize the healthcare system and one of my favorite expressions is, we've got to stop expecting people to come to health care and we've got to bring it to where people are and infuse it into their lives and the normal meeting places than the rest. And I think this has, there's great potential to do that. We have a lot of work to do there. And as you said we got to figure out what works and we have to measure it and manage it. But there's a wealth of opportunity and many great experiments for us to run in that arena. The second thing is I really like how you are connecting this back to the workforce issues and to the very serious issue of burnout. Now I will tell you, I prefer the term creating resiliency because it's a more positive way to talk about this. And you've touched on one issue which is as we introduce technology into the environment. Does that relieve stress and improve productivity and happiness or does it have the opposite effect. And I suspect you'd agree with me that, it's particularly in the last 10 years and clinical care it's a very mixed picture. So talk about that a little bit more, but tell us what are the other things that you see that are factors in mitigating burnout creating resiliency.

Dr. Kohli: Yeah I quite like the term creating resiliency Dave and I couldn't agree with you more. Look, it's a very complex issue and I don't think technology is solely to blame. But I think we can do better with technology to help improve the experience a little bit. I think access and burnout are intricately related. And let me explain how. When I hear my colleagues on the frontlines who tell Manish I am spending as much as 50 percent of my time in activities that I don't really enjoy and I'm not passionate about and I'm feeling really really burned out and I don't know how much longer I can do this. There is a fundamental opportunity lost that we need to be thinking about as leaders in health care, as individuals who are in a position fortunately to help drive some of this change. When you look at waiting times, when you look at access to care and when I look at a 50 percent drop in productivity in some of the most talented individuals, you think gosh if I was able to improve productivity by 20 percent, I could actually help reduce the access issue. And going a step further, if I was able to take care of the patient where they most needed to be taken care of. So if you have a patient could would be taken care of in the home rather than a clinic, we actually help the access issue as well. Not to mention the patient experience is much better. So if I'm traveling and I have a bad headache and I need care, I would much rather be able to call and have a teleconsult with my provider rather than have to go to an ED in some unknown country and not be sure of what kind of care I may or may not get. I think that opportunity is at all levels. If we start to bring the joy of medicine back, I think we can actually improve resiliency and I think on the flipside we are also going to help improve the access issue.

Dr. Dave Levin: Well I think you're onto something really really important here. And I would add two more things to it. So I think there's also an opportunity as we look at technology and we plan the workflows, the way the work will get done to engineer into this, the ideas of team care and creating the space for patients and providers to really connect, that can be very directly and concretely reflected in the design of the technology and how we deploy it and train for it. Wouldn't you agree.

Dr. Kohli: I absolutely agree and I would add one more thing to that, patient engagement. We can use the power of technology to engage our patients in some elements of pre care and health care, so that they are not only a part of the system but they're also freeing the physician and the nurse, if not some of that data collection task that we are spending a lot of time doing right now. 

Dr. Dave Levin: You and I have both had the great privilege and honor working with a wide range of health care delivery folks. And my experience and I'm sure you would agree is the vast majority are there because they've worked hard to attain a skill set and they want to practice their craft for the betterment of their patients. And that applies to the whole team. The pharmacist, the nurse, the doctor everyone involved and to some degree when we interfere with that, it really leads to this problem of burnout. I recall very vividly a recent podcast interview with Dr. Krista Darby who works in palliative care at Cleveland Clinic and one of the things that she talked about that was so moving was how in the practice of palliative care, she had the  luxury if you will of time to really connect with patients in a very authentic way. It's very interesting if you look at some of the data around burnout in our profession, palliative care has some of the lowest rates. It seems counterintuitive at first, because they deal with often with patients that end of life and always with patients who have very complex and challenging situations. And you might expect them to be burned out by that. But the data suggests. And when you talk to someone like Doctor Darby, that in fact the ability to really connect with patients in a meaningful way and make a difference creates a huge resiliency.

Dr. Kohli: You're so spot on and I think you talk to any health care practitioner. I mean I think they miss the joy of medicine that they had romanticized about when they started their training. And I think specialty that allow more contact time with patients, you're actually right ironically tend to have highest levels of resiliency. And I’ll also echo something you said earlier Dave. I mean health care is a team sport and team includes the patient and I think if we keep that in mind and start looking at who is the best suited to perform certain tasks and actually are smart about how work gets done. We could actually make a measurable difference in the experience that patients have and physicians and nurses and pharmacists and all healthcare team members have in delivering patient care.

Dr. Dave Levin: I think that's extremely well said. So Manish I want to turn to your favorite pet peeve or rant these days. But before I turn you loose I always remind my guests this is a PG 13 show. So please keep it family friendly. But what is your favorite pet peeve these days.

Dr. Kohli: You know it's one word, impossible. And I think there's an apostrophe missing in that word. It's not original, but I quite like it. I think that an apostrophe that belongs between the I and the M. Because we in healthcare must believe that I am possible. Nothing is impossible.

Dr. Dave Levin: I love that. I love that. And having worked with you I know that's an attitude that you adopt on a regular basis. So for the last question today what's your most sage advice and again having worked with you and traveled with you, I know you have lots of sage wisdom. What would you pick out to share with our audience today.

Dr. Kohli: Gosh Dave I'm still learning. So it's been a true blessing to be in this industry at this time, to work with great people. I really believe we're in the Renaissance phase of health care where in the next 10, 20 years as we look back I think we will have left something better than we inherit it. And I really tell folks I mentor that you have to really focus on the purpose. Why is it that you're doing what you're doing and really the colleague that I have talked to including you, we all believe that health care can and shall be better and we are all working hard in our own respective way. Then I would say that the joy of that purpose is what keeps us all going. I also tell folks look if you wake up every morning dreading going to work, you need to be asking yourself the question why. And if there's a change that needs to be made, you need to make that change. But we have to bring out the passion in people as leaders as well as individuals working. Because work to me doesn't feel like work. Because you wake up feeling energized and wanting to do something better than you did yesterday. And again recognizing that we are all privileged to be in health care to work with great people, to be an industry that actually touches people's lives and we should never lose sight of that. And bottom line we’re a people business, let's take care of each other, let's take care of ourselves. Because you know when we talk about resiliency in the workforce, It begins with us. So take care of yourself. You know eat right, exercise, manage your stress, work with your community. Spend time with family and enjoy life. 

Dr. Dave Levin: Well Manish I said at the top of the introduction that your dedication, humanity, empathy and passion would come through in this discussion. And it absolutely has shined very brightly here. I love your term we're in a health care Renaissance. I've been fond of saying I think things are bad enough that we're finally really going to fix them. But I'm going to adopt your term going forward that this is the Renaissance and aren't we privileged to be a part of that.

Dr. Kohli: Hear, hear. 

Dr. Dave Levin: Well before we sign off here you are a world traveler. What's your next big trip? Where are you headed off to next Manish? 

Dr. Kohli: My next trip coming up is to Chicago. But then I head on in a couple of weeks to the Middle East. 

Dr. Dave Levin: Very good. We've been talking with Dr. Manish Kohli, chairman of the global board of directors for HIMMS and president and CEO of Manish Kohli MD advisory consulting services. Manish thanks so much for joining us today. 

Dr. Kohli: And thank you so much Dave. It's been an honor and a privilege. 

Dr. Dave Levin: You've been listening to 4x4 Health sponsored by Datica. Datica; Bringing health care to the cloud. Check them out at www.datica.com. I hope you'll join us next time for another 4x4 discussion with health care innovators. Until then I'm your host Dr. Dave Levin. Thanks for listening.