Designing a Resilient Healthcare System
This week I am talking to Margaret Lozovatsky, MD (@DoctorLozo), SVP and Chief Health Informatics Officer at Novant Health (@NovantHealth). Margaret came into medicine with a computer science degree right at the time Electronic Health Records were being rolled out giving her an edge in both understanding as well as seeing the potential for the technology in healthcare,. This was further amplified at the University of Wisconsin Medical School located in Madison Wisconsin, home to one of the big EMR companies Epic. Margaret’s early experiences were still paper based providing useful insights into the challenges of chasing paper notes in healthcare and the difficulty of transition and the importance of change management.
Finding the efficiencies of EMRs and focusing on the positive change that allowed for easier access to information was important in helping bring her colleagues along:
“helping them understand how this can be used to their benefit, and also continuing to hear their concerns, I think is critical. My approach is always to understand what the challenges are, and to try to find solutions to make it easier”
Many of the challenges associated with EMR’s were linked to the transition from paper to digital and the failure to change the approach, she compares this to taking a computer screen and putting the same thing on a mobile phone, something that doesn’t work very well
“I like to compare the transition from paper to the HR to the transition from a computer screen to an iPhone, you would never take the same website and put it on an iPhone the way that it is on the computer, right? Because you need a different user interface, what we tried to do is we tried to take paper and put it into the computer”
We discuss the Race Car Designed TeleICU Carts (Stewart-Haas racing expands partnership with Novant health) that came about through a partnership with Stewart-Haas Racing that helped them develop and make ICU webcam carts for Novant Health.
Listen in as we discuss the importance of the quality of data going in to the systems, how to achieve that and where Natural Language Processing has reached and where it might get to turning data into information at the point of care. We talk about how Novant Health was well prepared to handle the pandemic that caught so many and what others could learn form their foundational approach and the importance of meeting patients in their community. We discuss the challenge oftentimes being the only woman in the room and what helped her navigate a successful career including the importance of seeing people like yourself as models to follow. Listen in to hear her incremental suggestions for developing your own career pathway in informatics.
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Raw Transcript
Nick van Terheyden
Today I’m delighted to be joined by Dr. Margaret Loza Vasquez. She is the chief health informatics officer at noble Margaret, thanks for joining me today. Thank you for having me. So as I do with all my guests, I think it’s important to understand a little bit of background, you’re a physician, but not a purely clinical physician, you have a whole host of other skills and talents. Tell us a little bit about your journey to get to this point, both as a clinician, but also as an informatics professional.
Margaret Lozovatsky
absolutely happy to do so. So I started my career in Madison, Wisconsin and medical school. Before that, I had completed a computer science degree. And when I went to medical school, it was the time when all the electronic medical records were getting implemented. So as I like to say, I sort of grew up with technology. And because I had a computer science background, I very quickly found myself being the go to person, people found that I understood the language that the IT team spoke and the language of the clinicians. And so that’s how I got into it. And initially, I really just wanted to make technology work for providers. So I started fixing small things. And from there, my role grew to first have responsibility for improving documentation, then working in optimization, and now as a CMO and transitioning to a CTO role.
Nick van Terheyden
Now, I’m guessing here, but Madison, Wisconsin is not the home of a rather large EMR than
Margaret Lozovatsky
it sure is, that is very observant. So interestingly, during my years in medical school, that organization implemented epic, and I have used epic throughout my career, I have had a lot of wonderful experiences with them, and then ended up living through multiple implementations, again, in residency, again, as an attending multiple times and then most recently as a CMO. So I’ve seen many different aspects of technology implementations and how it’s used in the clinical spaces.
Nick van Terheyden
Did that give you additional exposure, because you were proximate to that organization, and particularly through, I would imagine many of the growing years for that company, right?
Margaret Lozovatsky
It absolutely did, which was very interesting, because I got a lot of the inside views of how these implementations happened. So early in my medical training, I also ended up training as a physician builder, I was in the very first class that epic ever offered. And so I learned a lot of the ins and outs at that time, and then was able to have the opportunity to do some of that build, work with the analyst and learn that side of things, which has been really helpful to me in my informatics journey. Interesting.
Nick van Terheyden
So as you think back to that time, were you would, would you describe yourself as the odd one out in your medical school class? Did? Did you find other people that had similar views? Or were you really sort of separated by your computer science degree that sort of influenced your acceptance of the technology?
Margaret Lozovatsky
I did often find myself as the odd man out, both in medical school and in residency as I was living through these various implementations, particularly because I was often focused not just on what needed to happen with the technology, but thinking through what are the areas that we can improve before clinicians. So just to give you an example of something that’s fairly small, but was very impactful, one of the first changes that I had helped bring into being was the fact that as a pediatrician, as you might imagine, weight is critical in taking care of patients. We can’t order anything without knowing the patient’s weight, and the weight was buried in the chart. So you know, it was 20 clicks to get to this weight. So I had suggested that we put it up in the header, so you can always see it when making orders. This is a simple, simple change. But those are the kinds of things I found myself doing as I was practicing medicine constantly looking for ways that we can improve the system.
Nick van Terheyden
Yeah, it’s, it’s an important point, that sort of ability to see it through the lens of the clinician, as well as the programmer because from their perspective, sitting in isolation, they don’t necessarily perceive that they don’t understand this sort of, you know, importance of those data elements and you know, how people sequence it. So, you know, fascinating to hear that as you sort of progress Through. So, you know you’ve you’ve gone through a number of institutions. Tell us a little bit about some of the experiences of electronic medical records. I imagine that, you know, you’ve had to bring some of your colleagues along in that activity. I mean, it’s certainly my experience, it hasn’t been all easy. People don’t go, whoo, we’ve got the EMR. Tell us how you’ve approached that, and some of the experiences in that process?
Margaret Lozovatsky
Yeah, absolutely. And I think your observations are right on. Change is hard. Change is hard for everyone. I trained, as I mentioned, starting with paper, right? Even though I lived through the implementations and my training, I have vivid memories of chasing down vitals, you know, by every room on paper and writing paper notes. And so I think that this was a huge mindset change for clinicians. The way that I like to approach it, understanding how challenging change management can be for folks, is really to help highlight the areas that make things easier for people. And that I think, is a positive message that we can all send, there are certainly challenges with transitioning from paper to electronic medical records. However, the efficiencies that it brings the ability to see the entire patient charts, the connections to other institutions, the interoperability that we have now all started to take for granted really, is critical to our ability to take care of patients. And so as I have lived through many of these changes, this is the way that I like to approach it, I think that physicians are all very bright, and they’re usually very logical. And so helping them understand how this can be used to their benefit, and also continuing to hear their concerns, I think is critical. My approach is always to understand what the challenges are, and to try to find solutions to make it easier. No matter how much effort we put into streamlining the EHR is there always things that can be improved. And so I continue to see patients myself so that I can experience it firsthand. And I also like to round as often as possible and talk to the clinicians at the bedside, so that we can continue to iterate and to optimize.
Nick van Terheyden
So as you look back, I mean, I one of the things that always strikes me about the electronic medical record is that we took the paper charts and said, Let’s replicate that. And that, for me was a core failure. I think it was a missed opportunity. We could have rethought it. But that’s not unusual. I mean, it was the same in the industrial revolution when they introduced motors, you know, they put the motors at the end of pulleys, although they didn’t need to, you know, lots of history. So it’s not unusual that Madison did that. As you look back. What do you think we could have done better at the outset that would have helped in this process? Is it user interface? Is it the sort of data capture? Where do we miss opportunities in the early days? The thing?
Margaret Lozovatsky
Great question. I talked about this all the time. So I think there’s a couple of aspects of this, that now that we look back, we really should have thought about, I like to compare the transition from paper to the HR to the transition from a computer screen to an iPhone, you would never take the same website and put it on an iPhone the way that it is on the computer, right? Because you need a different user interface, what we tried to do is we tried to take paper and put it into the computer. And that is an obvious failure on everyone’s part, because people weren’t thinking far enough ahead to understand that the data needs to be stored differently. And so I look at the EHR, like a filing cabinet, right. So there are different areas where information needs to be stored, and it needs to be put in the correct place, so that it can later be retrieved, which was not the same in a paper record where you had your Daily Note that everything was in there. That’s how you communicate it. Now you have all these different pieces, you have the history, the problem was the medications and everything needs to be stored in an appropriate setting. And so that I think was part of what was missed early on, that we’re still trying to catch up on and educate clinicians and how to document in a way that is logical. The other piece that I think was amiss for everyone is understanding that as we start to use the electronic medical record, we have this amazing opportunity to collect data in a way that we never did before. And we really needed, in my opinion, to be a little bit more proactive in understanding that what you put in is what you get out. So if you’re not thinking about the workflow from that on Said inputting data into logical areas that can later be retrieved and thinking about discrete documentation, we’re not going to be able to benefit from this amazing tool that we have.
Nick van Terheyden
So I want one of the push backs I get and you know, I’ve spent a lot of time and the speech industry natural language processing the capacity to sort of take what is unstructured data and turn it into structured or at least extract it. And in fact, at the most extreme end, there are some folks that would say, we don’t need to structure anything, because we have the capacity to find appropriate pieces of information with advanced search capabilities and the ability to tease out meaning something that our brains do. I don’t want to say naturally, we do learn it, but we’re pretty good at that. Computer Systems certainly used not to be but they’ve gotten better. Do you think that need for structuring is still as important as it was back then when we didn’t have those capabilities?
Margaret Lozovatsky
That’s a really good question. I would agree that we have certainly progressed in some of the NLP capabilities and other ways of retrieving non structured data. But I would say, I don’t think we’re there yet. And I really don’t feel like I have seen an effective way to gather that unstructured data that is accurate and reliable, at least not today. I think you’re right that, you know, for thinking into the future, we’re going to get to a point where that will be feasible. I think today, we still really need the structure data. Part of the challenge with medical narrative is the context matters. So it goes way beyond looking for certain words, it’s really looking at the context and the tone, and so much of it is so challenging to translate into information. So we gather the data, right, but we needed to become information and we needed to be actionable. And today, I think we still need to rely on discrete data for that.
Nick van Terheyden
You know, and fair comment. I mean, here’s here’s somebody sort of promoting NLP and saying, We don’t need structure. But you know, I’m full of structure around here. I still have files on my computer system. You know, I focus on all that, because that’s partly the way my mind works. So I think you’re right. I just hope that at some point, we don’t, I’ve heard, you know, almost forever that, you know, we won’t need to structure things. You can just dump everything in and you can always find it. I find that it’s never a data problem. It’s always a search problem. So, you know, I agree with you. So those of you just joining I’m Dr. Nikki incrementalist. Today, I’m talking to Dr. Margaret Loza, Vasquez. She is a chief health informatics officer at Novell, we were just talking about data storage and the opportunity of NLP the structuring that’s necessary. And you know, an important point here, what you put in is what you get out. So rubbish in equals rubbish out, I think is, you know, the, the negative view of it. But the good news is, if we put good data in, we can get great data out. As we sort of fast forward, we’ve gone through an incredible sort of change innovation as a result of the pandemic. It’s impacted everybody, it’s hard not to sort of bring that up on an ongoing basis. And in the case of a health system, no one was quite well prepared, right? You You were positioned in a good circumstance to be able to, I want to say pivot, it wasn’t really a pivot, it was just, you know, flexing alternatives. Tell us a little bit about both the preparation and you know, some of the solutions that you have in place?
Margaret Lozovatsky
Yeah, that’s a fantastic question. And I’m very proud to be a part of this phenomenal team, because I think that what no one has done so incredibly well, is to be forward thinking and trying to plan for the future. The team has set up a foundation that has allowed us to pivot in many situations. And of course, nothing tested that more than the pandemic that happened last year. And that is still here today as we’re now in another surge and again, having to pivot as we think about solutions. So no vond in general, has always looked at how can we further our digital health capabilities, we really try to center our solutions around the patient, realizing that the patient is going to need care in multiple settings. And so we really try to look beyond the traditional inpatient ambulatory EDI vision of healthcare, and try to meet the patients in the communities where they are in the foundation for digital health was really very far along when the pandemic hit. So it really took 48 hours to get all of our physicians transitioned to be able to provide digital care to our patients. We felt that that went incredibly smoothly, because we had laid the foundation, I would think that that would be the biggest lesson learned is putting processes in place to be able to make changes quickly and effectively as healthcare is ever evolving.
Nick van Terheyden
So, as you think about that foundation, what were the elements that sort of contributed to that? How How did you make or how did no Vaughn be this flexible organization that was able to do that? What were the elements that contributed?
Margaret Lozovatsky
What one of the major elements in allowing us to be able to flex was to build teams in a way that allowed them to do things quickly. The philosophy is that we can often do things ourselves, and we build things in house. But we can move faster. If we’re looking at experts in other fields, perhaps that may not be traditional partners. And so one of the things that no one did during that pandemic, is really to look at partners in the field that may be able to help us and they looked at partners that are not traditional organizations that you would think of in healthcare in as the rest of the world was shutting down the some of those companies had ability to use their resources. So one of the examples of what we had done is that there was a race car manufacturer in the area that had top notch engineers that were not doing their regular work because of the pandemic and no bond, as you know, supply chain was shut down at the time, so was struggling to figure out how to stand up tele ICU. And we partnered with this company to help us build ICU carts. And so we were able to get the tele ICU up and running within months at a time where people were struggling to get any of the equipment that was necessary for that.
Nick van Terheyden
I’ve got to say the image for me is racecar manufacturers in ICU. And I just have a vision of this fast moving activities in ICU which can be fast moving, but not quite in that visual. That’s great. It’s you know, this adjacent possible and capitalizing on those experiences. And obviously, no vamp was able to position itself well with the telehealth capabilities video. You know, standing up the whole physician group in 48 hours, you know, is an impressive task given that, you know, many folks still struggling with that, and you know, certainly integrating it. As you move forward and you think about things in the future. Tell us a little bit about what you see and what you’re hopeful about. And also, if you can comment on the fact that, you know, as a woman in this industry, there are specific challenges. How did you manage? And how should others think about this?
Margaret Lozovatsky
That’s a great question. You know, when I started in informatics, I found myself as the only female in most rooms. And I think that what has been amazing is that it has allowed me to have a somewhat different, unique perspective. And I have been very fortunate to have amazing mentors that have given me the opportunity to grow in this field and have supported me throughout. As I reflect back on the last 15 years, or so that I have been doing informatics, the field has really changed the number of females is growing. And that I think, is a testament to the fact that we realize that diversity is really important and having different opinions and different experiences that people bring to the table is critical. So it’s sometimes challenging for folks to see these opportunities when they don’t see someone that looks like them in a particular field. And it’s important for all of us to come Continue to sponsor and mentor young physicians and help them if they have an interest in this field to grow their skills and expertise. There’s a lot of wonderful opportunities. When I started in informatics, really, we were at the elbow of support, right, we were folks that help people use the computer and show them which button to push the role of the instrumentation. And now the CMO, CH i O, continues to evolve in it has grown to be to really not only be a recognized specialty, which is fantastic. So there’s now a board certification, which I have been fortunate enough to obtain. But it’s now even got sub specialties within it. So people are looking at population health and digital health and all of these different areas. So the opportunities are infinite. And it’s it’s a great way to be able to help all of our clinical users, as they’re seeing patients, it impacts 1000s of users 1000s of patients, and that, to me is a fantastic opportunity.
Nick van Terheyden
So in the closing minutes of this, as you look back at your career, what would you so first of all, I would say, you know, the good news is that there are people that others can look to that look like them. I think that’s an important point about diversity. You know, if you don’t see somebody like you, you’re less likely to enter. Hopefully, that’s getting better, still not good enough, but improve. So there’s that it sounds like mentors are a big part of this. What would What advice would you give yourself, you know, many years back to sort of help navigate that? Because I imagine it’s not been a smooth process. And there have been challenges. What would you tell somebody back at that point in their career that might help them?
Margaret Lozovatsky
If If I had to look back and think about what would be most helpful, I would say that it would be really important to to be proactive, ask questions, continue to seek out opportunities, take those opportunities as they come up for you. But most importantly, try to learn about the various areas within medicine that may be of interest to you. Find people that you admire, and ask them for a little bit of time, ask them about their career, ask them about what they’re doing. I learned best when I was inquiring about the experiences of others. And I continue to connect and network with people all over the country, because I think that’s very important. So the networking opportunities is another piece of advice, go to conferences that are focused on that topic, and continue to learn as much as you possibly can.
Nick van Terheyden
Fantastic. So last couple of minutes, what are you most excited about for the coming years? I mean, obviously, we’re going to continue to deal with the pandemic and the, you know, downstream impact of that, whether it turns into or I guess it will at some point turn into an endemic or some other version of this. But what are you excited about? Where do you think the future lies?
Margaret Lozovatsky
Great question. I am most excited about where medicine is moving. In the future, I think about the fact that we’re going beyond the brick and mortar traditional model. And we’re going to be able to provide care to patients and all kinds of different settings. So thinking about hospital at home and remote patient monitoring, and how we can bridge all of the different areas within a patient’s healthcare, to help them improve their wellness preventative care. And I’m also really excited about some of the artificial intelligence machine learning opportunities that will help us predict some of the poor outcomes and hopefully get in front of them. This whole opportunity to monitor the patient and have a more holistic view of the patient, to me is where medicine is going in the future.
Nick van Terheyden
Fantastic. Well, unfortunately, as is always the case we’ve run out of time. It’s been great to catch up with you. I appreciate both all the work and the trailblazing that you’ve done and sharing some of those experiences. Really enjoyed the conversation. Margaret, thanks for joining me today. Thank you so much for having me.
