Dan:
Karen, welcome to the show.

Karen:
Thanks, Dan, and thanks for having me.

Dan:
Sure. Karen, you've had an awesome, amazing career. You've been a CEO of a hospital, you've worked in public policy, you've done secretary of health for the state of Pennsylvania, just an amazing array of different things. What drew you to the particular role at Geisinger and what's your mandate there?

Karen:
Well, I was drawn to Geisinger, really all my experiences have always valued the spirit of innovation. And really as my career trajectory took place, I acknowledged the fact that innovation, I think, is really what is going to help solve a lot of our problems across the industry. When Dr. Feinberg recruited me to Geisinger, I was really excited about the opportunity because the reason I was recruited was to begin to operationalize the Steele Institute for Health Innovation. As everyone knows and I always say, Geisinger had a national reputation for innovation long before I arrived. But to come to an organization with the innovative spirit that Geisinger has, I thought we could all work together and really produce some meaningful outcomes.

Dan:
That's really great. And Geisinger and the Steele Institute have their hands in a lot of different things. Can you talk about some of the highlight projects that you're really excited about?

Karen:
First of all, I always point out when I talk about the Steele Institute is to define what innovation means for Geisinger because I think we've all seen innovation centers across the industry and across the country, and innovation really translates to many different things for different organizations. For us, I thought it was really important to define innovation at Geisinger and to talk about really how we were going to approach the idea of innovation.

Karen:
We define innovation as a fundamentally different approach to solving a problem that has quantifiable outcomes, and that's important in a couple of different areas. The first is, we only work on problems. We really don't choose innovation for the sake of innovation, so we only work on problems. We employ fundamentally different approaches. I think there's a clear difference between performance improvement and innovation. And I think we have to have performance improvement throughout what we do, but innovation is different then that. It is a fundamentally different approach. And then we have to have quantifiable outcomes, so we always measure in design innovations that enables measurements to determine whether to scale; or quite frankly if it's not working, then whether to discontinue the work and move on to something else.

Karen:
Keeping that definition in mind, the Steele Institute has been organized to support our work and clearly define our projects. We are working under two pillars. One is health, where we take a look at fundamentally different approaches to population health and social determinants. I think two good examples of projects that we're working on, one that is national. It certainly has been nationally recognized is our Fresh Food Farmacy, where we've initially used a bricks and mortar approach to offer food as medicine to tie to food-insecure diabetics in an effort to produce better outcomes in controlling their diabetes. And we've seen preliminarily some really impressive results on movement declines in hemoglobin A1C and also engagement of preventative health, more of an engagement with primary health care services as well as a better quality of life.

Karen:
So building on the experience of our... What I mean by bricks and mortars is we actually have buildings and staff in what we call Fresh Food Farmacies where patients and their families come in and pick up food that is healthy, and are engaged with clinical nutritionist. They're engaged with pharmacists, they are engaged with the entire clinical team, all designed around maximizing the benefit of clean food to enhance their outcomes and prevent exacerbations and also progression of their disease.

Karen:
Now we're launching... We're taking that approach of Fresh Food Farmacy and we've developed a digital application. And really taken a look at how do we take our learnings of our Fresh Food Farmacy that we've achieved with the centers for Fresh Food Farmacy that we have located throughout our markets, how do we take that in a digital way and test a digital application for Fresh Food Farmacy?

Dan:
Wow. Those are really interesting projects. It reminds me... So two things that you talked about really struck home, one, the idea of the innovation ecosystem. One side being the innovation process and kind of the fundamentally different approach, and then the process improvement. And what I'm reading in the literature is that organizations need both. Like you said, you can't have these fundamentally different approaches because you're always disrupting the system and it creates some chaos. On the performance improvement side, if you're just doing performance improvement, you're really just improving what you know. And so to combine those two to actually create fundamentally different programs I think is really good. Because then you can bring in the new ideas and refine them so they optimize, and then jump off again and do something new and refined and optimized, and that really struck home.

Dan:
And then the idea of the Food Farmacy is awesome. It reminds me of a video we shot when I was at another institution about how we could use almost augmented reality to help people decide which foods to buy and link it back to their care plans and then incent them through coupons and things to actually change their habits as they went through the grocery store. And it's kind of providing care anywhere people are instead of just the times that they're in our clinics, so that sounds really interesting as well.

Karen:
That's exactly right. And then another program that we have that we're really excited about is called, in the health pillar, is Free2BMom. The name of the program is free, spelled F-R-E-E with a number two, capital B, and Mom. And that program has been designed to help moms who are pregnant with substance abuse disorder and to support them in recovery. We wrap our arms around them when they enter medication-assisted treatment or other treatment, and support them with community services and social support services in hopes that after they deliver that they maintain their recovery and that we offer them supports that will lead to sustained recovery postpartum. I'm really excited about that. That's one that's philanthropically funded and we're really working to try to produce a motto that sustains moms throughout, not only their pregnancy but also after they have their baby.

Dan:
Sure. That's another great program.

Karen:
Thank you. And then the next pillar is Care Delivery & Payment Transformation. And we have two large projects under now, pillar one is we've embarked upon a three-year journey to redesign a chronic disease management leveraging technology, artificial intelligence, machine learning, remote patient monitoring and patient reported outcomes to change our approach to chronic disease management. Historically, of course, we've done chronic disease management leveraging case managers and other healthcare professionals that intermittent meetings with patients to do education to review their lifestyle clinical indicators. But what we've discovered is first of all, that model is extremely labor-intensive and that the massive growth in patients with multiple chronic diseases, we think that to do an efficient job is probably no longer sustainable. But we do think that we can develop a new model leveraging the technology that I shared, so we've embarked upon that journey.

Karen:
We're in the process of doing patient journeys, physician journeys and family journeys, and doing an assessment of what technology can we lay around and really redefine and transform the way we take care of chronic diseases. And then we have support services in our Steel Institute for Health Innovations, so we have an intelligent automation hub where we're looking at RPA applications with artificial intelligence throughout the enterprise. We have an artificial intelligence lab. We have partnered with external stakeholders, companies like Medial in artificial intelligence. And we've also developed an approach to artificial intelligence and machine learning within Geisinger. And then we have a product innovation team.

Karen:
And very recently, launched the digital transformation office where we'll not just apply digital technology that actually transform our processes and then apply digital technologies to enhancing the consumer experience and also improving our business efficiencies among our processes throughout the area. That's the large example, but that's the work that we'd embarked upon among the Steele Institute.

Dan:
That's amazing, and I'd love to dive a little bit deeper into the automation work in a second. But I'm interested, how is the Steele Institute funded? I heard there's some philanthropic funding. I'm sure some funding comes from a operational capital budget, but how do you maintain your innovation ecosystem through funding?

Karen:
You're exactly right. It's all three funds. It's operational funds, grants and philanthropic funding. And we are also raising revenue through some commercialization opportunities and also co-development opportunities with companies. Raising revenue, I guess that would be a fourth bucket where we raise revenue on the work that we do. Our goal would be in five years to be self-sustained or produce a cost savings that would equate to whatever funding expenses that we have.

Dan:
Yeah, that's always an interesting conversation with the CFOs I find. They want these hard dollar savings, but a lot of the care delivery innovations are actually reduction of risk or time back to clinicians to be able to provide the care they need to provide, and so it's always interesting to those hard versus soft dollars. I'm glad that the Steele Institute is being held to actually cost savings as well and not just generating revenue like I think a lot of organizations are pushing their innovation teams to do.

Karen:
That's definitely a challenge without question. I think the other challenge really that I see with innovation institutes, and I've been quoted saying this before, is that I think we expect short-term results from long-term strategies. And the idea that you can create a meaningful innovation in a short period of time is, I think, very unrealistic. And I think the design process is so important.

Karen:
The other is appreciating the idea of failure. I always say that if you don't have a list of failures as you evolve as an innovation institute, that means you're really not pushing the envelope. I think it's important to appreciate the value of failure, learnings of field initiatives as well as giving the necessary time and resources to designing innovation.

Dan:
Those are really great insights and points to make because it is a long-term strategy and there are a lot of failures along the way, but they're learnings and they hopefully will help the system evolve over time. You mentioned some work in the automation space and machine learning. Before we dive into some of those projects, what do you define as automation? I think there's some fear that automation implies that you're taking away work from a group of people. I would love to hear your thoughts and definition of how you look at automation in healthcare.

Karen:
I think that is a natural response because what we're actually doing is applying a robot to what we would traditionally classify as tasks that can be performed by the robot that do not require complex human thinking. It is a first reaction is that you're going to take jobs.

Karen:
I think in terms of my response really is that what we would really like to do is maximize human intervention. I think it's different in different areas. In the communities we serve,` workforce is a really significant issue. We have shortage of available workers to actually fill and sustaining our physicians. But I think it's a legitimate concern of all really, and I think we have to be cognizant of that as we promote these strategies. I don't think we can stop with the strategies because we have to lower the total cost of care and our administrative costs are a significant part of the total cost of care. I think we have to forge on, understanding that there's sensitivity there and really be cognizant of that when we go out with our messaging.

Karen:
I think when we think about transformation and we think about really disruptive innovation in the world and we think of the finance industry, 25 years ago we were pulling in the parking lot, getting out of the car and going into a bank to cash a check. And I don't think anybody has a recollection of the last time they did that, maybe other than go to an ATM machine, have had very little contact with their financial institution that couldn't be done online. I think when we look at retail and we look at the disruptors in the retail space, this industry is evolving and will evolve to this space and we have to be the one to disrupt it.

Karen:
So I think RPA offers an opportunity to lower our administrative costs. I think the good news is, the healthcare industry has kind of been late to the table in order to implementing RPA, so we have a tremendous amount of opportunity with [inaudible 00:16:40].

Dan:
Yeah, we definitely do. And I always say healthcare is about 20 years behind other industries in the adoption of technology. But you mentioned something earlier as well, that you've involved the clinicians and the care team members in the design-thinking process or the design process, which is so essential to actually building a viable solution. I'm wondering as you involve them in the workflows and you layer on some technology and automation on top of that, are they excited about that? Do they see it as an opportunity to be able to reduce burnout?

Karen:
At a place like Geisinger where you have such an innovative culture, we have tremendous clinicians that are really supportive of the work, and so it really is an honor to work with the team here because they embrace the disruption and innovation. They are always at the table.

Karen:
I talked about the Chronic Disease Command Center. Not only do we have physicians and nurses, I think, on the clinical team, on the design, but we also always include them from the very beginning of the discussion and engage them because they are on the front line with patients. And I really just don't think you can design a successful innovation in the absence of that clinical input.

Dan:
That's 100% true. I think in the theories of innovation, the people closest to the problem need to be involved in solving it, otherwise it fails. And even Roger's diffusion of innovation curve starts to drop if you don't include those opinion leaders and frontline doers. I love that approach, and it sounds like you have a good feedback loop in there.

Dan:
And you mentioned that healthcare is pretty far behind in the adoption of some of these new technologies like RPA and other machine learning type of resources. Do you have advice for other healthcare leaders on how they should start thinking about adopting automation or looking at RPA as a possible solution for some of the things they're working on?

Karen:
I would have the advice to first take the pulse of the organization in terms of readiness. I think that all innovation really requires starting with the CEO of the organization. I think you have to have a clearly articulated vision by the CEO as to what he or she desires the outcomes to be. I think absent that, I think everybody ends up disappointed. So if you're not clearly in line with what the governance and the leadership actually expects, you could very easily end up in a place that really doesn't meet expectations.

Karen:
I say number one, align vision and mission and strategy with leadership. I think number two, really work for projects in the beginning that are going to be quick wins, and I mean like in RPA particularly. Ones that are embraced by the operational units because operational people are busy operating every day, right? And when you come in and add another layer onto that operational complexity, it is difficult for them to find other times in their day and you have to have their input. I would say engage in operational units that actually understand what the complexity of work would be and what their requirements would be, and engage them to embrace the technology and actually work out the solution.

Karen:
And then I think finally long-term is... Well, first of all, I would go back to articulate and really explain to everybody what it means to innovate. And that if you really want to do something, like I said in the beginning, meaningful, it's going to take time. And I think really establishing reasonable expectations for what your work is in this space. And then I think finally pick on something that's really meaningful. Really that you can change, that you can move the needle. That is really a solution that you can find that not only helps your organization, but hopefully we'll make a contribution to the industry as a whole.

Dan:
That's great advice to consider. And one of the struggles I've seen in other organizations that I've been with is the idea of linking the innovation to strategy. And you touched on it a little bit, but sometimes I find two camps. One is the innovations can only be done around the strategic focus areas of the organization for that year or the coming five-year plan and then other organizations say, "Well, no, innovation is not part of our strategy necessarily. It needs to be over on the side kind of thinking about things we've never thought about."

Dan:
I wonder how do you position how you align your projects with the overall Geisinger strategy? Is it a combination of kind of focusing on the strategic goals and then some blue sky thinking or is it on either side of the spectrum there?

Karen:
I think it should be both. I think it should be blue sky thinking about the organizational strategies. I think it should be tied to the organizational strategies. I think absent that, you're not really creating value for your organization. If your strategic priorities are selected in a way that's thoughtful and actually produces the necessary change for your organization to be successful, then I think the contribution should at least align in most of the innovation projects that the innovation center's running.

Karen:
I think then what should happen is there should be blue sky thinking about, everybody else's thinking about the traditional tactics to employ in order to be successful with the strategies, let's as an innovation center think about different approaches to those strategies that maybe are not the same tactics as the general population is preparing. I guess the answer is I think you should do both.

Dan:
I tend to agree with that point of view as well. Another aspect I find in innovation centers struggling with how to execute on their mission and their innovations is the idea of "buy versus build". And so one of the institution I was at for a long time just built their own stuff because they had enough resources, they had enough it help, they even wanted to build their own electronic medical record at one point. And then eventually over time that switched to a kind of a buy mentality where they would partner with organizations and maybe work to influence the product strategy and then buy that product from an organization that was more expert in that. What are your thoughts on "buy versus build"?

Karen:
We have a product innovation team that does build when appropriate, but we really make the determination after we identify the problem. The resources required to build are significant, and I think if you can buy a product on the market that has been proven and successfully implemented otherwise, I think that's what to do. I think the place... I'll give you an example, Fresh Food Farmacy, we just built a digital application to that because we couldn't find anything on the market that actually matched what we wanted with a digital strategy and that's a unique brand in any unique program. But in other instances, I think you really have to consider in terms of being a good steward of an organization's resources. I think when there is an application that's performing at a high level, I think to expend resources to duplicate that is probably not wise.

Dan:
That's definitely a great a way to conceptualize it and frame that. And yeah, ultimately, healthcare organizations aren't enterprise software developers and so there's a level of expertise and resources, like you said, that is required to maintain something. But there is an idea of building even minimal viable products to even provoke the market to maybe develop some things that you would buy later down the road.

Karen:
Right. I think the other thing is when you're doing enterprise solutions, that's what you tend to do is enterprise solutions, not solutions that are generalizable throughout the industry. That's the other way we've pivoted. That if we're going to build a solution, then we're not going Geisingerize the solution. We're actually going to build it so that it can be, if successful, have the potential would be commercially successful as well.

Dan:
Just to pivot back to the automation side, you mentioned that you're held to some outcomes and you're really focused on impacting outcomes, what are some of the outcomes of the automation and RPA work that you've been doing? Some early wins that you're really excited about?

Karen:
We just started our automation lab last July and really spent the first couple of months building the infrastructure. We've only been at it since, in earnest, I would say producing bots since maybe November. We have a list of multiple projects that we've identified and we have three successful bots. The first three bots... And this may be a good place to start that addresses your earlier question about replacing jobs, we really went in and built a bot that was going to require a new employee, a hire for example. We built a bot to perform a payroll exercise and successfully avoided the need to hire. We've developed a bot in our context center that actually eliminates old backed-up orders, populates the Epic record. We eliminated 7,000 orders that were in the queue actually out of date initially and we're up to 12,000. Again, cost avoidance with employees that were required to do that.

Karen:
Bots on our list going forward include really heavy in the finance department, the pharmacy department. You talked about soft savings. For example, we're looking at employing a bod in our finance department that enhances the close process every month. Now that may not necessarily translate into a decreased FTE, but it will enhance the process of financial close on a monthly basis. We have a list of bots that are very important, and the team that works on bots always shares this with me. The most important part about building a bot is really that discovery process, and going in and building a journey of the process that we want to develop a bot to replace.

Karen:
And again, we never want to just digitalize or use technology to automate a broken process. It takes a real amount of time to really do that discovery phase in the very beginning. The more time you put into that discovery phase, I think the more successful the bot strategy will be. And then secondly, we look at applying artificial intelligence to the bots that we develop so that when there's a revision that we don't have to go back in and build a bot, that we actually have an automatic change built into the RPM.

Dan:
Yeah, I think you bring up the good point of technology on top of a broken process breaks it faster. Last question before we wrap up here, what is the number one thing you want to handoff to our listeners about automation?

Karen:
I think that it's a tool. I would say not just automation but all technology. We've tried really hard over the last 20 years to improve healthcare. We've tried a lot of strategies that, quite frankly, have not been that successful in improving outcomes and controlling costs. I think technology, it's an enabler. In itself is not a strategy. It's an enabling strategy. But I think it's a new tool that we have, that we haven't had in the past to this level, and that we should execute those strategies that include technology in order to transform the healthcare delivery system in an effort to decrease cost and improve quality.

Dan:
Karen, thank you so much for being on the show. If people are interested in the Steele Institute, Geisinger and maybe following more of your work, where can they find you?

Karen:
You can go to geisinger.edu and the Steele Institute is right on our website, and we have a contact box on that website that you're more than welcome to reach out. The team would be happy to embrace anyone that's interested in learning more about the Steele Institute.

Dan:
Thank you so much, Karen. These are great insights to help the healthcare leaders understand automation, innovation, and maybe how to build their own center. I really appreciate having you on the program today.

Karen:
Thanks, Dan. I appreciate you calling.

Dan:
Thank you so much for tuning in to The Handoff. If you like what you heard today, please consider writing us a review on iTunes or wherever you listen to podcasts. This is Doctor Nurse Dan. See you next time.