Gerald C.KaneHow DigitalTransformation IsMaking Health.docx

Gerald C.Kane
How Digital
Transformation Is
Making Health
Care Safer, Faster
and Cheaper
As chief information officer of Beth Israel Deaconess Medical
Center, Dr. John Halamka oversees digital strategies that are
designed to make patients safer and healthier while cutting
medical costs. “We’re able to manage risk because of this
digital footprint,” he says.
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How Digital Transformation Is Making Health Care
Safer, Faster and Cheaper
DR. JOHN HALAMKA (BETH ISRAEL DEACONESS
MEDICAL CENTER), INTERVIEWED BY GERALD C. KANE
As chief information officer of Beth Israel Deaconess Medical
Center, Dr. John
Halamka oversees digital strategies that are designed to make
patients safer and
healthier while cutting medical costs. “We’re able to manage
risk because of this

digital footprint,” he says.
Dr. John Halamka, chief information officer at Beth Israel
Deaconess
Medical Center.
“What I have to do across 2,200 employees, 83 locations,
4,000 doctors and two million patients is try to take a best
guess at what the future will be,” says Dr. John Halamka.
Halamka is a medical doctor (his specialty is emergency
medicine), but he has spent his career focused on
bringing technology to the medical world.
As chief information officer at Beth Israel Deaconess
Medical Center, Halamka is responsible for clinical,
financial, administrative and academic information
technology for one of the world’s leading hospitals. Based
in Boston, Massachusetts, Beth Israel Deaconess is an
academic medical center affiliated with Harvard Medical
School. Its services include cardiology, obstetrics,
gastrointestinal disorders and cancer care.
Halamka has been in the CIO position since 1997. Back

then, he says, he personally wrote the code for the
company’s health information exchange and for the
foundational work of Beth Israel Deaconess’ electronic
health record system (known in the industry by the
acronym EHR).
Today, he doesn’t write code. “The nature of what the
digital guy does today is more about influence and
organization,” Halamka says. His job is to help coordinate
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the integration of digital technologies across the dozens
of medical locations and, increasingly, right into patients'
homes. And he does it in an industry of intensely, if
understandably, tight regulation.

In a conversation with Gerald C. (Jerry) Kane, an
associate professor of information systems at the Carroll
School of Management at Boston College and guest editor
for MIT Sloan Management Review’s Digital Leadership
Big Idea Initiative, Halamka explains what his five
primary digital strategies are, how he deals with the
challenge of finding good talent in a nonprofit world and
why he found Google Glass intriguing but not ready for
prime time.
You’re in health care and you’re a digitally
savvy person. Set the stage for us: How is
bringing digital technologies to health care
different than other industries?
I have a $1.5 million fine if somebody sends a text with a
patient identifier in it. I’m betting that doesn’t happen in
most other industries. The constraint about data flows,
audits and security, is very significant.
Data integrity is very significant. What if data is
corrupted and your allergy is now missing? In another
industry, if a piece of data about you, say your frequent

flyer number, were missing, probably you wouldn’t die.
In our industry, there is zero tolerance for downtime. My
average downtime is six minutes per year. And people say,
“Were you asleep at the wheel or are you just dumb?
Babies could die in those six minutes.” Try to find another
industry for which six minutes per year, 24/7/365, is
considered an intolerable number.
And our funding is tight — in our company, we have
1.9% of the operating budget for health care IT.
So demand is high, regulations are significant and
funding is low. Those are just a few things that are
different about health care.
Tell us about what Beth Israel Deaconess
Medical Center is doing with respect to
digital strategy. What is you digital strategy
and how are you communicating that across
the organization?
Sure. As we all know, health care gets better by getting
bigger. So mergers and acquisitions are the theme of the
day. Of course, the Affordable Care Act now pays us for

performance and value, quality and outcomes, as opposed
to just more volume. So that implies if we’re going to
control all the means of production, if we want to ensure
consistent policy and treatment guidelines and keep you
out of the hospital and look at continuous wellness, rather
than episodic sickness, we do need more sites of care.
And specifically, patient-centered medical homes,
suburban hospitals, urgent care, skilled nursing facilities,
etc.
We have community hospitals, 20-, 50-, 100-bed
community hospitals for which MEDITECH [software
for electronic health records, or EHR] is currently used.
MEDITECH is fine for that size hospital, although with
every hospital we acquire, it’s a different version of
MEDITECH and a different configuration, a different
user experience.
So digital-strategy point number one is to take every
single-instance of MEDITECH in the empire, move it to a

single instance cloud-hosted web-enabled application. A
little edgy. MEDITECH has agreed, as we are the first
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customer for this, to host it and use a subscription-based
software as a service model for MEDITECH, with one
single instance for all our sites.
Digital strategy number two is ambulatory care. It turns
out, MEDITECH is not a great ambulatory system. So
you look at the world out there and you’ve got the Epics,
the GEs, you’ve got eClinicalWorks, you’ve got Athena, a
few others that are not doing so well in the market.
EClinicalWorks, a client-server–based application, has
been our incumbent ambulatory care system, but it is
very challenging in an agile world. Athena, cloud-hosted

subscription model, runs on anything anywhere; much
more agile. So digital strategy number two, move the
entire empire ambulatory care system to Athena.
Digital strategy number three is expanding
caremanagement. In a world where your funding is
dependent on outcomes and wellness, you need
something beyond an EHR. An EHR is fine for a single
doctor to do analytics, but it is not enough for population
health or care management. Two years ago, we built a
care-management medical record that today receives
thousands of transactions a day from disparate EHRs
across the empire. That provides a single, consolidated
view to care managers, non-physician folks, who are
looking for gaps in care and for deviations from protocols
and guidelines. It can be used for initiating visiting nurses
in the home, telemedicine, teleservices visits, scheduling
appointments, looking at activities of daily living and
social support. These are the sorts of things you need to

do to survive in a risk-based world.
So far, by the way, using that care-management medical
record, Beth Israel Deaconess care organization has
become the number-one ACO [accountable care
organization, tying reimbursements to reductions in the
total cost of care] in New England and the number-three
ACO in the entire United States. That’s because we are
preventing redundancy and waste, and we’re focusing on
keeping you well in your home, as opposed to seeing you
for more ICU stays or emergency visits.
Digital strategy number four is engaging patients and
families. They are seeing the notes written about them.
They are contributing to the records, structured and
unstructured data. Their devices in the home are
connected, like blood pressure cuffs and something like
Apple Watch one day. The idea is that you need data
about weight and glucometer values and various vital
signs if you’re going to look for interval change between

office visits and make interventions. The patients and
families articulate their goals for the visits, and the care
team then shows them progress against those goals. We
don’t want to give more care, we want to give right care.
Giving patients and families on BYOD [bring your own
device] devices the ability to see digital dashboards of
their communication preferences, care plan, goals and
progress certainly helps.
And then digital strategy number five is to make sure we
comply with all the various federal regulations, whether
that’s ICD-10, meaningful use stage one, two or three,
HIPAA rule, ACA, etc. Of course, we have done things
like leverage the state’s health care information exchange
to its greatest extent to achieve the various
interoperability requirements.
So that’s, in brief, the digital strategy, and that is probably
communicated to every manager and every supervisor. I
go to what are called leadership meetings to explain it. It’s

well known among the senior management team.
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Published extensively on my blog. Broadly communicated
in every stakeholder meeting I have with other CIOs
across both our community and the country. As well, at
Beth Israel Deaconess, we have engaged governance.
With all the board members we reemphasize the digital
strategy we’ve had in FY15 and what we’re executing in
FY16.
You have a very clearly articulated digital
strategy. What have been the most significant
challenges you’ve dealt with as you’ve sought
to implement the various aspects of the
strategy?
Well, strategy number one. Do you think that the CEO or

the senior executive business owners come up to you and
say, “Do you know what we really need? We need an
omnibus, continuous care-management platform for
population health and analytics that will help us
understand variations in cost and care, so we can
maximize quality, safety and efficiency?” No. The senior
executives say, “I don’t know what IT we need. I’m not
really sure.”
So how do you get a set of crisp requirements and
specifications that are going to be foundational to an IT
project? Or do you try to get together, bottom up, a bunch
of people and skate where the puck is going to be? You
guess.
In effect, what I have to do across 2,200 employees, 83
locations, 4,000 doctors and two million patients, is try to
take a best guess at what the future will be. That’s sort of
strategy issue number one. Not top-down command and
control.

Number two, budgets. In this world of declining
reimbursement, it’s not as if I have vast amounts of cash
to go try a bunch of things. I have to be extraordinarily
focused in my efforts, and be cheap. The entire cost of the
MEDITECH cloud ends up being not particularly
different from the costs that IT and the community are
incurring today. In effect, we’re doing innovation and
doing projects in a totally cost-neutral way.
Challenge three, compliance and regulatory burden. I
have to share more data with more people for more
reasons, but never spill a byte. Because if I do, I have a
$1.5 million HIPAA omnibus rule fine and the attorney
general crawling down my back.
In a world with change, the health care environment is
basically undergoing a radical redesign as we move from
fee-for-service to value-based purchasing. Every
stakeholder wants their own thing, maximizing each
individual silo. Governance is a real challenge. Saying no,

making sure the institution agrees on what we’ll do and
what we’ll not do, and trying to keep people satisfied
when they’re told no. That’s kind of hard.
And then finally, a strange thing. Most for-profit
companies will pay out generous bonuses, give you stock
options, everybody has a Tesla Charger in their parking
space. But in nonprofit organizations, I have very little to
offer employees to recruit and retain them. I am
competing with social media dot-coms and EHR vendors
that pay much better than I do. So recruiting and
retaining talent while I’m executing a digital strategy is
hard.
On that last point, how do you recruit and
retain digital talent in this highly competitive
environment? And what to do you look for?
The first is to find people who are mission driven. Do you
have any idea what the CIO of HCA [Hospital
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Corporation of America, a U.S. for-profit operator of
health care facilities] makes per year?
No.
He makes $3.7 million. That would be slightly greater
than 10 times my salary. That’s in Nashville. So people
who are working in nonprofit health care are not doing it
for fame or fortune. They are doing it because of a sense
of mission. And so you find people who really feel just
good about their making a difference.
Number two, you make the organization seem so
innovative and cutting edge that people want to work
there to be part of the next new thing. Beth Israel
Deaconess was the pilot site for Google Glass, the pilot
site for Apple HealthKit, we have the Apple Watch.
And number three, we create a family environment. In 20

years, I have never had a resignation of one of my direct
reports. You create a collegial place to work, where we
never have blame or negativity, and where we examine
the process that failed, not the person who failed. People
feel very supported in that environment. So it’s a
combination of mission and excitement and family that
seems to be successful.
What have been the biggest outcomes? What
are the benefits that are being realized?
Our goal is zero harm. It is very difficult in a paper-based
world to reduce harm, but we haven’t had a handwritten
order in 12 years. Every single med is dispensed with a
triple check, with barcoded meds and barcoded delivery
and the pharmacist oversight. It’s all digital. So you
reduce harms — that’s certainly a significant outcome.
We have 80,000 monthly users of our shared medical
record, where patients and families are contributing and
looking and reading and engaging and securely

messaging their clinicians. That digital workflow has led
to significant patient satisfaction and patient retention.
We’re able to provide layers of decision support and
analytics that are probably greater than most institutions
because we have the data collection instruments and the
warehouses, data normalization and health care
information exchange. We’re able to manage risk because
of this digital footprint.
If you can look into your crystal ball, what are
the biggest changes facing digital and health
care coming in the next three to five years, or
whatever timeframe you can project into?
How about a month from now? We all are seeing this
mass migration to mobile. Eighty percent of the website
accesses at Beth Israel Deaconess are mobile based. The
desktop is dead, the laptop is dying. Instead it’s tablets, it’s
mobile phones. For us, ensuring that our patients and our
doctors have the tools they need to do the tasks they want
in a mobile environment — while securing it — is kind of
an interesting challenge.

I mean, the number of security issues that we’ve had over
the last year — state-sponsored cyber terrorists,
hacktivists and organized crime. Embracing BYOD and
mobile in a world filled with an Internet that’s a swamp,
that’s a challenge.
What do you get excited about as far as how
digital is changing health care? Do you geek
out on anything? Do you say, “This is really
cool, what we’re going to be able to do”?
I don’t geek out on anything. I’ve got a lot of equanimity.
Not high highs or low lows.
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But from personal experience — my father died two years
ago and my father-in-law four months ago — what you
realize is that there are gaps in our digital world we need

to fill. How do we ensure that physician orders or medical
orders for life-sustaining treatment, end-of-care
preferences, goals, are transmitted across the continuum?
Are they stored on your phone and then shared with a
caregiver? Are they on a registry where they can be
accessed by anyone? There are still a lot of advance
directives, health care proxies and physician orders for
treatment moving around on paper. It’s very
disconnected.
I think it’s increasingly important that we do get
information from the home of all kinds, which means
teleservices, telemedicine, care in the home. I believe that
Minute Clinic and those kinds of urgent cares will have
an increasingly important role. Walgreens is beginning an
infusion program, for example. So when my wife was
diagnosed with breast cancer, she was driving in on the
Mass Pike hours every week, when, in fact, there’s a
Minute Clinic 50 feet from our farm that now could

conceivably do her chemotherapy infusions. That’s lower
cost, with higher patient satisfaction. It requires that the
digital record be sent through the health care information
exchange, to share it with all the caregivers.
So those sorts of things — more connectivity, reaching
into the home, more patient centricity — those are
exciting.
Where do you find the time to stay ahead of
what’s next, or what you could be doing,
given new technologies coming on the
market? How do you remain innovative?
It’s important to have an individual contributor pushing
innovation. Because otherwise, innovation will get lost in
the tyranny of the urgent.
Do you think that applies beyond health care
as well?
Oh, I do. Do you think it’s IBM that makes the big
innovations? Of course it doesn’t. It’s the two or three
guys or gals who come together and innovate and drive
some new disruptive solution home. Not large, lumbering

companies. So whether it’s a person or a small group, a
skunkworks, it’s that sort of thing.
Tell us about your Google Glass project in
delivering health care. Did it work?
I was asked to pilot Google Glass in health care. What we
decided was the use case would be the emergency
department.
The plan was this: We lock the devices in a safe. A
physician comes in, unlocks the safe, takes out a device,
puts it on. Logs in by looking at a QR code that is unique
to that individual physician. So a physician is now in the
department, on shift and logged into the glass. As they
walk into any room, they look at the door. On every door
is a QR code. The registration system assigns patients to a
room. Therefore, the physician knows which patient is in
the room they’re walking in. They can see the problem
list, medication list, allergies, laboratory results, care
plans and other things in Google Glass as they are talking

to the patient.
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So we went live with it and deployed it. It was, I think,
four pairs of Glass across eight doctors, who used it for
several months. And then we threw it away. Because it
worked flawlessly from our perspective, but the Google
Glass was a horrifically engineered device. Used a TI
processor that overheated. We had one pair melt. Had a
one-and-a-half-hour battery life. Wi-Fi didn’t roam. It
didn’t have Android updates. It had security problems.
So it was just a prototype that was not ready for prime
time. Of course, we think wearable computing is really
great and important, and we will be happy to use a device
in the future that actually works.

So you’re not using that at all right now?
We can’t, because it can’t hold a charge for more than an
hour and a half and they melt.
Wow. Okay. What about Apple Watch, you
mentioned that one.
Yes. The idea was this: If you have a patient with, for
example, multiple medications, that patient may not
understand what medications to take when. So what if, on
the Apple Watch, you gently tap them using the optics.
You show them a picture of the pill to take. After they
take it, they tap the watch and you have a patient-
generated electronic medication administration record
showing compliance with medications.
And? How did that experiment go?
So I am a white male, and I have very little body hair, and
it turns out that the watch works fabulous on me. But if
the watch is put onto a dark-skinned person, especially
one with a lot of body hair, the sensors don’t work. Apple

in its release scaled back a lot of its health-related
telemetry goals, and focused more on fitness — how
much did I run, that sort of thing. We may get there, but
at the moment the design of the sensors just don’t work
for everybody.
We’ll see. It’s, again, kind of an expensive thing, and it
requires that you have your phone. So I think the jury is
out as to what adoption will be in health care.
So that’s two examples, the Apple Watch and
the Google Glass, that didn’t live up to the
expectations you had initially. How do you
approach new technologies given these kinds
of hiccups? Does it dissuade you?
Failure is a valid outcome. What I mean by that is, we’ve
learned that wearable computing is great, but Google
Glass is not. And therefore, let’s just wait until the
technology is ready. Or with Apple Watch, we may
discover the patients love it, and therefore it is a platform.
Or not, and that’s okay. We just don’t know.
My traditional final question, is there anything
I should have asked that I didn’t?

Just recognize that as you talk to IT leaders, it is just really
hard to be an IT leader in the current environment when
you are being asked to change the wings on a 747 while
it’s flying. Total security, total reliability and stability, with
complete innovation at the same time. And so I sort of
wonder, as we go forward to the future, will people want
to take this role? Or maybe the role has to be recast and
the tasks divided across multiple individuals so they can
deal with the pace of change and the stress.
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c.57109Wx_14033.pdfHow Digital Transformation Is Making
Health Care Safer, Faster and CheaperHow Digital
Transformation Is Making Health Care Safer, Faster and
CheaperYou’re in health care and you’re a digitally savvy
person. Set the stage for us: How is bringing digital
technologies to health care different than other industries?Tell
us about what Beth Israel Deaconess Medical Center is doing
with respect to digital strategy. What is you digital strategy and
how are you communicating that across the organization?You
have a very clearly articulated digital strategy. What have been
the most significant challenges you’ve dealt with as you’ve
sought to implement the various aspects of the strategy?On that
last point, how do you recruit and retain digital talent in this
highly competitive environment? And what to do you look
for?No.What have been the biggest outcomes? What are the
benefits that are being realized?If you can look into your crystal

ball, what are the biggest changes facing digital and health care
coming in the next three to five years, or whatever timeframe
you can project into?What do you get excited about as far as
how digital is changing health care? Do you geek out on
anything? Do you say, “This is really cool, what we’re going to
be able to do”?Where do you find the time to stay ahead of
what’s next, or what you could be doing, given new
technologies coming on the market? How do you remain
innovative?Do you think that applies beyond health care as
well?Tell us about your Google Glass project in delivering
health care. Did it work?So you’re not using that at all right
now?Wow. Okay. What about Apple Watch, you mentioned that
one.And? How did that experiment go?So that’s two examples,
the Apple Watch and the Google Glass, that didn’t live up to the
expectations you had initially. How do you approach new
technologies given these kinds of hiccups? Does it dissuade
you?My traditional final question, is there anything I should
have asked that I didn’t?

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