Dan:

I'm excited to have you on the show, Rich. Thanks for joining.

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Rich:

Oh. Hey, Dan. Thanks for the opportunity.

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Dan:

Yeah. This'll be fun. I'm super interested about your role and I think others would be too. One of the themes we have on this show is talking to people in non-traditional roles, in nursing across healthcare. And so can you give just a little bit of download on what you're up to lately and what your role is at SAS?

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Rich:

Currently, I serve as an advisor to SAS. So SAS is the founder of analytics back 40 years ago, it created some of the initial statistical software that has now gone on to be used around the world and doing the fancy terms we call today like AI and machine learning and those things. A lot of that was built off of software that was developed by Dr. Goodnight over 40 years ago. And so we do this around the world and every industry and as you know, healthcare has some of the most challenging and pressing need for applying advanced analytics. And so I serve now in this role at SAS is helping advise and guide SAS in some of our strategies and how we can better apply some of our technologies into healthcare and work with a lot of our healthcare clients and helping them build out their analytic capabilities both in working with IT but more so, what I'm interested in is making that useful and usable to the end users and particularly, nurses and nurse managers.

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Dan:

I love that. And I think the terms, AI and machine learning and all of those information rich, data poor, have been thrown around a lot lately especially, I just came back from the HIMSS Conference where every booth was touting some sort of machine based something or other. How did you find your role from nursing graduate to a technology and even a statistical software company?

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Rich:

Yeah, I joke and say, today, any company that can spell AI says that they do it or think they can do it and that's been my experiences. Now, as I've really started to come see under the hood and learn what that really takes to do it well, we've been doing it for a very long time and we continue to lead in this space. So now I've really gained an appreciation for what it takes to do this well. And in healthcare, it is critical that we do this well. And so for me, that journey started back when I was a nurse, I worked as a nurse for about 10 years before I pivoted my career into this field of "informatics". And we can define that a little bit better as well but the pinnacle of my clinical career, I was a flight nurse for Duke in Durham, North Carolina.

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Rich:

I did that for about six years and towards the end of that was where we were starting to see a lot of this new EMR adoption coming out. Everybody was implementing Cerner and Epic and everything and Life Flight. We had our own system that I started to get more involved in managing and trying to customize. Because I would get very irritated when I would go on a 15 minute flight and it would take my colleague and I an hour to document what happened in 15 minutes. And so I was constantly looking for ways to make that more efficient, more usable. So I'd start off by just doing things like taking screenshots and PowerPoint and trying to overlay like, "Well, what if we documented pain a different way? So I'm not free texting everything out or every time." That right there would save five minutes, every flight or whatnot.

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Rich:

And then trying to submit that and working with the vendors to say, "Hey, can you make these changes for us?" And then those would get implemented nationally. And so this all of a sudden it started to realize that I've got a little bit of a knack for this. And that led to an opportunity where I was able to take a leadership position with Life Flight. I look back at that now because I was the youngest member on the team and they gave me a position of leadership. I took on the nurse manager role for that team and that's where I began recognizing, so I thought, "Okay, well now I've got this role. We've got all this data that we're generating so let's see how we can start putting this to better use." And then realizing as we've all come to realize at some point in our career that we can't do hardly anything with that data.

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Rich:

And so that was a realization for me that nurse leaders or any leader of the future has to have a keen awareness of how to utilize data and information to lead well. And the upcoming blurring line between operational or organizational leadership and this domain of IT, that those are continuing and I think we've seen that and COVID has brought those closer together to where to lead an organization well today, you have to understand how to utilize and how you're in part an informaticist as well.

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Dan:

I think that's something that's important that well, informaticist are a certified and specialty within nursing. There is an aspect of that skillset that needs to be in part of all of our practice. So for the frontline nurse or the nurse leader who may not be a certified informaticist, what does that look like for them? What skillsets or where can they be trained in order to get that skillset and bring it into their evolving practice as a nurse?

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Rich:

One of the best frameworks that I keep coming back to that I learned and so I started off in me trying to understand, "Okay, there's this new field of informatics? What is this?" And so I found a certificate program just to try to learn a little bit more and that at the time was very focused on EMR implementation and project management and the science of EMR implementation. And I think as we've found is, that's very quickly evolving and expanding into a much broader domain. Informatics is no longer just about implementing and maintaining an EMR but how do we think about that as the application of technology towards new innovation and new models of care delivery and making care more efficient and the experience of delivering care better for the nurses and for the other clinicians. And so there's this framework that we often talk about in this field, talking about the DIK framework and what it is talking about... Thinking about how do we turn raw data so the D, into information that produces knowledge, that's data to information to knowledge.

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Rich:

But ultimately, what we're trying to derive is new insight and wisdom. And so at every point along that journey, we need to start thinking about the technologies that we have and that we're trying to implement in so much as what that does along that framework. So we've got these EMRs that are these transactional systems that are collecting all this data for nurses to be mindful and thinking about how that is efficient, what the data that they're putting in, to be thinking about what that produces on the back end and for the nurse leaders and for the informaticists and for IT to be mindful about how they are showing value from that data and delivering that back to the front lines. Because I think that's where there's still a disconnect that we have a lot of ground still to cover so we're showing that value. So that will then in turn make it more valuable for the nurse to understand why they're inputting all this data.

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Dan:

I think a lot of people think that informatics is just the EMR and how do you document... And rows and flow sheets and all of that stuff and it goes so much deeper than that. I mean, I've had the privilege to work with a colleague, Ann O'Brien who was at Kaiser and now is at Ascension and the scope of what the informaticist did was just amazing. I mean, everything from using statistical analysis to reduce the number of alarms that trigger for nurses to thinking through the devices they use and what they can do more passively, I guess, from a documentation standpoint, by having a phone in their hand to clinical communication and how they communicate orders and other critical needs between the team members and all of that falls under the scope of the nurse informaticist.

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Dan:

And I think a lot of people see CMIOs, the chief medical information officers and think, "Oh, that's who runs this stuff." But I think we have to remember that nurses are the biggest users of documentation and have upwards of 20 systems that they have to navigate in any given day in order to get the work done. And so that role of the CNIO, the chief nursing informatics officer is so key. So where is the field of nursing informatics in its evolution towards claiming that spot of, "Hey, we are running the show here on these pieces of technology and we need people to represent our voice here."

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Rich:

Yeah. For all the challenges of COVID that we've experienced over these last few years. One of the things that makes me hopeful to see is how nursing has been brought more into the spotlight. One of the big talking points, I constantly, am educating my colleagues at SAS and so when we look at these technology companies that they're not providing care. So they're not in the trenches on the front lines, immersed in healthcare day to day is helping them see how these organizations really operate under the hood. And to your point, the chief nursing information officer, the chief nursing officer, those are the positions as the nurses and the nurse managers that are really at the end of the day, every day, getting stuff done. So to help our type of company and technology companies and all these companies that are in the digital health and innovation and trying to find new ways to work with these organizations, recognizing nursing as the critical stakeholder.

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Rich:

But at the same time, we've got to work with the administration teams to also give voice to their own internal teams and allowing that CNO and those nursing leaders to have more of a voice and to think through how do we start supporting them and giving them more autonomy and decision making power to run their units and their departments and divisions and hospitals. And we do that and one of the big ways is, so now that then elevates this role of informatics and the nurse informaticist beyond just someone who's maintaining the EMR and ensuring that we're checking the box on all, on documenting all our quality standards and CoTIs all those types of things. But how do we actually, turn this asset, this data that we're generating into a strategic asset and put that in the hands of these nurses to make more and better informed decisions. So I think it's a consistent messaging and helping our industry recognize the role that nurses play and I think COVID has helped to start to unearth that a bit.

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Dan:

Yeah. And coming off HIMSS, I met with lots of vendors there across the board and looking for emerging technology as well as some of our strategic vendors. And I was surprised at how many, even established well known companies are just now entering into nursing in technology. But what they're doing is... And this is not across the board but there were several meetings I had where they were repurposing physician based workflows in technology for nursing. And they're wondering why it wasn't working for them and why the nurses weren't adopting it. And one was around documentation. And I just remember having a conversation, the nurse workflow is not the physician workflow, the way physicians chart and the history and physical and some of their process, soap notes and things aren't the same as clicking boxes and checking things and which doesn't lend itself to more ambient technology voice and other things because it's so complicated. What advice do you have for some of these organizations when they jump into nursing as their next user base, what should they be looking out for? What are some of those differences that you see?

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Rich:

The biggest thing is, hire nurses. You can't design for nurses without nurses and that's the biggest thing. The frustration that we see with a lot of these EMR vendors is they well hire programmers out of college but then you look and you start to dig into how many actual clinicians they have on their team and they're very few. There is an EMR company that I have had the privilege of working with early in my career called modernizing medicine. And I look to them as the gold standard. So what they realized very early on a Dan Cane who founded and sold Blackboard so that education technology platform down in Boca Raton Florida met a physician, Dr. Michael Sherling, who is a dermatologist. And very quickly realized that it was quicker to teach Dr. Sherling how to code than to teach Dan how to be a doctor.

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Rich:

And so they actually, have clinicians that do the coding in their platform and they are different per specialty. So I would love to see the same model adopted across technology vendors, where they're employing nurses. Because coding and programming is more and more becoming automated. Our technology here at SAS is, we're starting to see more of those types of things being automated. So for nurses who are interested in informatics, the next step is not to go learn how to code, the next step is to really start to inventory and assess and make sure you're learning and you understand workflows and how to analyze workflows and break those down into their components, storytelling.

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Rich:

When we think about things around design thinking and systems thinking, those are much more important. We can automate the coding pieces of it, the technology aspects. But translating that into code and into technology is where that critical next step is. And so employing clinicians, I think is the critical piece that you have to have. Like we said earlier, it's your CNO that are at the end of the day, really making the care delivery happen. And so a lot of these companies that get this infusion of funding and they'll go, and they'll hire a chief medical officer at ungodly amounts versus thinking through and hiring a chief nursing officer or somebody who has a much better and broader understanding of healthcare as a system.

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Dan:

Yeah. I've noticed similar trends in any organization. And I see it in a lot of startups too, that they immediately go to our physician colleagues. And if they're building a product for physicians, that's the perfect place to go. But if you're building a product for nurses or the nursing workflow then you need to have that expertise and there are some organizations that have doubled down on that and others that haven't. I know one of my first roles at Kaiser Permanente was being that translator not knowing how to code but knowing enough about that and not being on the floor but obviously, having experience in that and being that translator for IT teams to think about the nuances of a clinical workflow. And I remember one time there's a large company named after a fruit came in one time and said, "Hey, Dan. Can we spend 30 minutes with you to understand nursing?"

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Dan:

I'm like, "Sure. I can give you an overview. What are you trying to do?" "Well, we want to build a product for nurses, there's 4 million nurses." And I said, "Sure, I can tell you about that. Do you want to know about inpatient, OR or ICU, outpatient?" They're like, "Oh, there's all that?" And I'm like, "Yeah. We could spend years talking about all this stuff," and they're like, "Oh, wait a minute. Well, can you just tell us what nurses do?" And I think people that aren't in the healthcare space or engineering it from a technology standpoint, think, "A nurse is a nurse is a nurse," but there's so many specialties and nuances between workflows and all kinds of stuff that you just... There's not just one size fits all opportunity here. I know we have a lot of listeners from technology organizations listening to this too that may not be in healthcare, just entering healthcare. What advice do you have besides hiring a nurse? What are some of those key pieces that they need to think about as they're building technology that's going to touch our frontline nurses?

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Rich:

Oh, yeah. I cringe every time I hear that, "A nurse is a nurse is a nurse," I can't hear many times, I've been told that early in my nursing career and it would make the hairs on the back of my neck bristle. The good place that I often will advise companies as far as where to start is just to ask them about their personas. They've to go a lot back to just a design thinking approach and how a lot of the more successful companies outside of healthcare have started and have been successful and they will often develop customer consumer personas. And that I think is a very still new concept to healthcare, we're still trying to figure out this whole notion of patient experience. And there's a lot to be said about that but my thing is, "Well, why don't we apply that same approach?"

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Rich:

And this is why I've done this in some of my work with other organizations is, let's create personas about our nurses so we can understand really what it's like to be in their shoes. And so to the extent that we can do that across the various roles of nurses and sure, like you said, it is very complex. So to the extent that we can start to develop these sets of personas to understand really what it is that a day in the life of a nurse looks like, I think any ways that we can help create empathy and we're trying to design a product or develop a product for another user, that's the best place to start.

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Dan:

Yeah, I agree. I think that persona piece is key and that's why design thinking is part of what I preach as an innovation process as well. In your role now you get to touch a lot of organizations and what are some of the most creative things that you're working on at the moment that is using that nurse persona to drive some innovation within healthcare technology and data?

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Rich:

Well, so much of the industry is focused on the clinical piece and rightly so. There are plenty of challenges that we need to solve there. What I get more interested in, we could call it the low hanging fruit, the opportunities for innovation are really around the use of more of the operational data. And I think back to early in my career and that was one of the things that led me into this path around informatics and no two paths are the same either by the way, how we all navigate our careers. Lately, I've been calling it a game of shoots and ladders if I'm trying to find a board game. But there are no linear paths in our careers as nurses, I think that's a strength of nursing as well so we can go and we can try out different things and create our own career journey. But using that operational data and trying to find ways to create efficiencies and systems and improve the experience of care, I think is critical.

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Rich:

And so when I look at organizations and some of the ones that we're working with particularly, with nursing right now is tackling the challenge with nurse recruitment and retention. Interestingly, as nurse managers, we often have a span of control of, right. We might have 30 to... At one point I had close to over 70 people that I was directly managing.

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Dan:

Wow.

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Rich:

You come to another organization like I talk with my colleagues and some of these technology companies and if you have more than eight, they're like, " That is a bad thing." They're trying to start thinking about how do you split that team? And that's in a relatively flat organization. And so again, this goes back to just recognizing the complexity and the voice of the nurse and these personas and the nurse manager being a key persona of that as how can we deliver better information and insight to that nurse manager to know what's going on with that staff of 70 nurses or let's say 50. You might have a better idea of what the average direct report ratio is today because you can't round.

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Rich:

There's all these things we're talking about, you have to round on all your employees every week or whatever. That was something that came out on early in my management careers. I was supposed to have a one-on-one touchpoint with every direct report, I think it was every other week or something like that. But we can use technology and apply analytics because we're pulling in enough information now from the EMRs around how they're documenting, when they're documenting. You've got various HR type data time and attendance, those types of things, different modes of communication that are being collected electronically. We can analyze all that stuff and we're doing that in a way to then be able to surface only the most relevant alerts to where a nurse manager can prioritize who they need to talk with and about what and how to intervene. So we're identifying employees that are at most risk of burnout or of leaving the organization or even worse at risk for suicide.

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Rich:

So those are the types of challenges that some of our organizations are using analytics to solve for, that I think are delivering immense return on investment. And then you've got other things around new models of care delivery, like hospital home and using data and information to identify patients that would be appropriate for that level of care. Those are the types of things where we're challenging the status quo. I got my hands slapped once though because I suggested to a system that maybe instead of investing a hundred million into building this new 35 bed hospital, they should invest 10 million and stand up a hospital home program. So they don't take kindly to that often but those are the types of things when I see some organizations that are really trying to push the status quo in some of those new models of care, that gets me really excited and the extent that we can show that and track and demonstrate that value both for the system, for the clinician and for the patient, I think is critical.

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Dan:

Yeah. I laugh at that story because I've had similar conversations. And I always question the hospitals like to put out this press about, "Hey, we're building this billion dollar new tower with 500 new beds or whatever." And I'm like, "But the trend of healthcare is moving outside of the hospital. So what is this, are you going to make them apartments at some point or something?" But it is so funny that we're still stuck in this old model of volume driving healthcare reimbursement. And I was in another conversation with a large academic medical center one time too and we were working on this diabetes research project and they're like, "Well, we have to have those patients come in, we have a lot of no-shows and blah, blah, blah, to get their blood sugars checked." I'm like, "Well, why don't you just do virtual visit with them and give them a Bluetooth glucometer?" "Oh. Well, we can't get reimbursed for that visit so they've got to come in."

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Dan:

And I'm like, "Man, these are the decisions that just are breaking our system," and people don't want to put up with it but they also don't understand the reimbursement picture. And I think the more we can get embedded into these technology based workflows and we can document and have data around the value of a nurse and what their day to day is and what impact they have to individual patient care which I hope will change the reimbursement picture as well to say, nurses aren't part of the room charge. That they have a direct impact on the length of stay and the outcomes which we know but I think we need to do more research around it and get that data out there because that's the only way that all these things that are currently impacting our nursing colleagues around pay and workflow and ratios and that stuff is all, we need data to support these things to change. And that really lives within the systems that nurses need to be involved in the building.

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Rich:

Yeah, exactly. And so it's on us as technologists and informaticist to be able to show and demonstrate that value back to the nurses. It's this cyclical loop because if you don't see value in what you're spending hours doing in front of a computer, you're not going to be as committed to that. And by no means, do I want to make any nurse or cement this notion of a nurse as a data entry specialist, I want to get rid of that. But to be thoughtful about what it is that you are documenting because you see the value that it has down the road and to your point, the extent that we can start to separate those things would help prove in a nearer term that relationship, that the trends towards this value based care again, all those things have been held back by our inability to really utilize and access the data.

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Rich:

So we talk about a patient that's diabetic that needs to get in the office that is a frequent no-show. There are ways to be able to not only identify but then to your point, deliver that care virtually. And yes, maybe we deliver that encounter at a loss but can we track the value that, that has over that patient's lifetime or the course of treating that patient because we are getting them in front of a clinician. We are managing their care more proactively, we've got that in-home glucometer other types of remote patient monitoring there in the home that's helping them manage their care and helping us keep a passive eye on that patient and alerting to a need to interact with them at the most timely points along their care journey.

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Rich:

And is that keeping them out of the hospital because these costs... We've got to start thinking more on how do we mitigate and manage these costs and not just, how do we keep inking out these little incremental revenue driven encounters. And so this trend towards value based care is helping, we've still got long ways to go but again, I think that missing link and ultimately, why I came over to a company like SAS is because we need to be able to apply these advanced analytics and to really helping to create and tell that story in a way that a nurse can understand, you don't need a PhD in Statistics to build, to interpret this data. And so we've got our ways to go towards democratizing that.

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Dan:

Yep. And I agree because Statistics was the one course in my PhD program that I just could not wrap my head around so I did qualitative studies.

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Rich:

Could I confess that same here and now I work for the leading statistical company in the world but, yeah.

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Dan:

Hey, but there's experts, I get it. That's the thing is, you have to know enough to understand why but there are people that can dig into how much better than probably, you and I can.

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Rich:

Absolutely.

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Dan:

And I think just to double down on one of your points is, we don't need this evolution. We need a revolution in how technology and nursing play together and I think now is the time and with the rise of informaticist and that specialty, there's no time than now to get and engage 4 million users which I know any software company would love to have 4 million users at their back end call so I think about it like that... Well, Rich, we're coming to the end of our time here and I know we could go on for hours and maybe we'll have to do another show, a deeper dive on some of these topics. But we like to end the show with handing off that one nugget of information that you'd like our listeners to walk away with. So what would you like to hand off?

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Rich:

Well, so I just came back from Disney. We just got home yesterday from our first trip to Disney. I took my three kids, 10, seven and three. And one of the quotes that have stuck with me that I saw, I can't remember what ride we did. But it had a little quote from Walt Disney that just said, "Around here we don't look backwards for very long. We keep moving forward, opening new doors and doing new things because we're curious and curiosity keeps leading us down new paths." So I've been memorizing that and rehearsing that quote in my mind since I've been down at Disney. A, because curiosity is a core value at SAS and just as we continue to talk about innovation and how to drive innovation, what are the challenges towards innovation and application of technology? I keep coming back to that word curiosity.

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Rich:

And so maybe that handoff or that takeaway, if you're listening to this right now is just to take a minute to do an internal reflection on how you are championing curiosity whether you're demonstrating that by the example I shared earlier, I was frustrated by how the EMR was trying to capture pain documentation. So I took screenshots and put it in a PowerPoint and did little overlays and tried to push that forward. But more importantly, if you're in a position of leadership, how are you fostering curiosity within your workforce?

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Rich:

And empowerment is not just permission. It really is about thinking through how are we providing resources and support to foster these ideas that the nurses are bringing to the table often expressed as frustrations and I get that. And sometimes that's hard to just listen to but how do we turn those into... And foster and support curiosity for them to be able to pursue a solution. And so you think to an organization like Disney, who does that so incredibly well and at the core of that, Walt Disney is saying, is this value of curiosity. That might be my handoff, my encouragement to everyone listening is just to think through how do you create a culture of curiosity?

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Dan:

Yeah. I think that's a great piece. And it's always question the why, always question what you're doing. Evidence evolves, data evolves, found your practice on that and ask the question and it will take you down crazy pathways, just like you and I have in our careers. We've always asked why and I wonder if and if I was there, what could I do? And it seemed to work out. So Rich, thanks so much for being on the show and I really appreciate the conversations. We'll dive deeper in it as well. At some point in our near future. Where can people find you if they're interested in learning more about you and your work?

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Rich:

The best place honestly, is LinkedIn. And I know we're still trying to move more nurses onto that type of a professional platform. It's done wonders for me and my career and developing a professional network. So if you're not on LinkedIn, I encourage you to get on. And if you find me, I will help you set up your profile if that's what you need. But if you're on there and you're active on LinkedIn, that's probably, the best way to get connected with me either following me there or reaching out and sending me a message. I'd love to hear if you found me or got connected through this podcast, I'll make sure to send that back to you, Dan.

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Dan:

All right.

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Rich:

To let you know, but I'd love to get connected. And if you do that, I promise I'll make time for you. Because I think as nurses, we have to continue building each other up and I love seeing nurses getting involved in these ways because every nurse can't and we don't want every nurse become an informaticist like we said at the start of this. It is a competency that every nurse does need to have whether I can help support you in your career and moving more into a formal position or just understanding how to start applying more of these technologies and digital solutions into your day to day care delivery. I will do everything in my power to help you with that.

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Dan:

Awesome. Yeah. Thanks, Rich. And we'll put some of that in our show notes as well. And I think LinkedIn, it continues to be the number one most referred platform for getting involved in non frontline bedside sort of stuff. And we need to change that as well to get the frontline nurses on there as well as open up opportunities away from the bedside. So Rich, thanks so much. I appreciate your time. And everyone check out the latest episodes of the handoff and we'll see you next time. Thanks so much.

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