If you ask Aaron Miri, the biggest problem with healthcare is that it was designed in the 20th century using a waterfall model. “To flip that on its head,” he said, is going to take “a long time and a lot of fortitude.” It’s going to require abandoning the 5 and 10-year strategies of the past and adopting an “iterative planning cycle where you’re constantly reassessing.”
It’s an approach that has served Miri well, both in his current position as Chief Digital and Information Officer at Baptist Health, and in previous roles with organizations such as Dell Medical School & UT Health Austin, Imprivata, and Children’s Health. During a recent interview, he spoke with Kate Gamble, Managing Editor at healthsystemCIO, about the “continuous learning environment” his team has cultivated at Baptist; how they’re leveraging robotic automation to enable clinicians to practice at the top of their license; how philosophy when it comes to fostering innovation; and why he believes “courage and conviction” are such important qualities for leaders of today and tomorrow.
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- Opening a new, state-of-the-art hospital comes with state-of-the-art challenges, said Miri. “It all has to come together into a symphony of everybody playing their part really well so that opening day goes as smoothly as possible.”
- The best way to determine whether the right workflows are in place? By “getting in there, talking to folks, partnering, and rounding.”
- “We cannot grow our nursing, medical staff, and allied folks fast enough. What we can do is enable and empower them so that they’re working smarter, not harder,” said Miri when discussing Baptist’s approach to robotic automation.
- True innovation doesn’t come from buying shiny new toys; it comes from having the right approach. “You have to have a definitive why, you have to want to do it, and you have to have the courage to ruffle some feathers.”
- The biggest problem with healthcare? “It was built in the 20th century with a waterfall methodology. To flip that on its head takes a long time and it takes a lot of fortitude.”
Q&A with Aaron Miri, CDIO, Baptist Health
Gamble: Baptist Health just had a new hospital open on December 19. Can you tell me a little bit about that?
Miri: Yes. Baptist Medical Hospital Clay, a state-of-the-art hospital serving Fleming Island. It’s our seventh hospital. I was looking at the census, and we’re almost at capacity. We were almost there two and a half weeks after opening. It’s crazy. It’s good for the community because the demand is clearly there, but bad if you think about the people in the area — what were they doing before this?
But that’s indicative right now of healthcare in general. Everyone is dealing with a massive tidal wave of demand. Everybody is sick.
Gamble: Opening a new hospital is something you’ve done before. But it’s never really easy, is it?
Miri: That depends on how you define easy. But no, it’s not. There are so many things to navigate. At a high level, you have to navigate construction and material delays, right? That goes into technology as well.
You have to navigate people. When do you hire your staff to start? When do you get them trained? There’s a cost consideration there. Then you’ve got process. Are you redesigning units? Do modifications have to happen because you’re going to provide a different type of care? Are there certain services you’re going to offer on Day 1 versus Day 60? All of those things have to be ideated.
And of course, it all has to come together into an orchestration layer — a symphony, as I call it — of everybody playing their part really well so that opening day goes as smoothly as possible.
In our case, we transitioned from a freestanding emergency department with a surgical bay — there are eight bays — to a hospital. We added a tunnel connecting the two so that folks can go between them. We already had staff there; we just had to grow them to now do labor and delivery and all these other service lines we have, there along with the pavilion.
And it’s all state-of-the-art. But that comes with state-of-the-art challenges. And so, things come up, and you have vendors you need to call upon for help. But in our case, it was December 19, right before Christmas. Do you really think all of your vendors are going to be responsive? You have to work through all those permeations. It’s a logistical opportunity for sure, but with good leadership comes good results. And that’s what we had.
“We had great planning”
Gamble: We’ve heard a lot about staffing challenges. Did you run into that? How did you deal with it?
Miri: We had really great planning with our HR team. They had a line of sight on recruitment for several hundred clinicians, nurses, and allied health techs to staff the hospital to open up at a certain census, and we had good projections on what we figured the demand would be. It wasn’t like we were building a hospital and had no idea about the area. We had a freestanding ED. We had surgical services. And so, we had an understanding of how busy we would get and what the ebbs and flows would be.
With that historical data, we were able to project — and this is a credit to the planning teams — when we needed to pull the trigger with hiring people, and when they should start. We actually started them a few weeks early, even though the building wasn’t ready for patients, so we could start training. We had folks training within the EMR, getting them up to speed. A lot of folks actually transferred to other hospitals because it’s closer to home. That was a win-win componentry across the board.
The hardest part in all of this is making sure that your processes and your workflows are truly identified. Because even within a health system, one hospital is one hospital. You can’t just replicate what you do at, for instance, our downtown, large tertiary care center at a 100-bed hospital. Those are very different types of patients you’re seeing.
“Agile on the fly”
Gamble: That’s really important. I’m sure it’s a key focus from day one. What can you do to make sure the right workflows are in place?
Miri: Elbow grease. It’s getting in there, talking to folks, partnering, rounding, doing ‘day in the life’ activities. My clinical informatics team does what I call ‘holding court.’ They work with the nurses and clinicians to say, ‘Here’s how it happens. A patient presents at registration, they go to the ICU, they go to discharge — whatever the case may be. One of our CI analysts became Patient Jane, and they walked through the whole process, with clinicians making comments like, ‘This works well.’ Or, ‘this is kind of funky. Why don’t we do it this way?’ If you do that enough times, it’s almost like agile design on the fly, and you’re able to create a process that’s, in our case, 90 percent there.
You’re going to learn a few things over the first few months. We had a case where twins came to the NICU. The process we had designed was for individual babies. And so, having twins — both with complex conditions — meant we had to have double the amount of equipment or a certain type of level of sensitivity for our monitoring systems.
Culture of learning
You learn things as you go along; you adapt, document, and go forward. The good news about Baptist is that our culture is a continuous learning environment. Anytime we learn something new, we go back and teach everybody else so that we can incorporate it at our future hospitals. Given the culture, the attitude, the learning environment, and the leadership, we were able to come together and get it done.
Core objectives for 2023
Gamble: Aside from the new hospital, what do you consider to be some of your core objectives for 2023?
Miri: A lot of it is around the industry pressures that everybody is facing. You have financial constraints — how do I simplify the tech stack, which is my applications? How do I modernize things so that we can reduce overhead, and become more cost-efficient so that I don’t have to hire an army of people net new, but instead, make do with my existing team?
Second, how do I address burnout and uplift my existing teams so that they’re educated on new technologies, and they feel empowered and supported? It’s not our job to replace your personal family, but it is our job to create a work family where you feel supported and happy, and you want to be here. How do we do that? How do we make sure we’re listening to the staff?
Beyond that, how do we deal with really sad situations that are happening across the world with people engaging in self-harm and substance abuse? How do we make sure people get help so they can deal with those things in their personal lives, and they know that work has their back? That’s the people development piece.
Filling “unprecedented demand”
And then there’s growth. We’re in a high growth market. We have something like 100 net-new people moving to the greater Jacksonville region every day. So, we’re dealing with volume.
The growth rate is actually faster than Austin, Texas, which was where my previous organization was located. This region is booming. In fact, Forbes listed Jacksonville as the second-best place to live in Florida due to affordability and availability of housing. And it’s close to the beach. As a result, we’re dealing with unprecedented demand. It’s a good and bad problem to have, because it stress-tests all of your systems. We want to make sure we can accommodate that and do what we’ve been doing since the 1950s, which is providing the best possible patient care to this region. And this is why Baptist is a preferred provider of care for our area.
Gamble: Do you foresee more growth to be able to serve the growing population, whether it’s through brick and mortar or other ways?
Miri: When it comes to brick and mortar, I think you’re always going to have that element of it. I think it’s going to slow down across the industry, largely because of cost and because of delays getting gear. For instance, it takes 18 months to get a simple network switch. And that’s the case with any network vendor because of supply constraints out of the far east. That becomes the long tail where I can’t get concrete. I can’t get coax cable for the longest time.
You’re not going to be building new buildings. You’re going to be doing virtual development of programs and more hospital-at-home and care-at-home programs and or doubling down to make sure you have effective partnerships with people in the region who do these things very well.
Let’s come together and do a joint program. We don’t have to buy them out. Let’s partner in very strategic ways so that we help everybody. That way, the entire region has access to care, whereas if you build a new hospital, that may not happen.
That’s driving a lot of the fuel of M&A in our industry. The question will be, how will payers react? They might say, ‘we’re not paying for this. We’re going to want you to cut your rates.’ And if you do that, there’s a whole calculus occurring right now that we have to work through that will become more about virtual health and joint programs, as less about and building something and hoping they’ll come.
Automation & robotics
Gamble: Well said. Another area is automation and robotics — it seems like Baptist is doing a lot there. Can you talk more about that?
Miri: Thanks for asking that. I’m really proud of our entire leadership team for doubling down on robotics. First, there’s automation using languages like Ansible and others to script back-office systems, and using systems like HIRO for chat bot engagement with patients. That’s one type of automation.
Then there’s robotic automation. We’re the first health system to deploy Moxie robots throughout our children’s and adult hospitals to help nurses work at the top of their licenses. Why not program a robot to retrieve linens? Why do they have to be away from the patient and the bedside? If you go to Las Vegas and order room service, a robot brings it to your door. Why can’t that work for getting clean linens, for delivering food to a patient room, or for retrieving blood from the blood bank until. Why can’t we automate that with robotics?
Work smarter, not harder
And so, our executive team did a pro forma analysis and decided it was a worthy investment. We’d give it a shot and reevaluate in 12 months to see if we have the ROI to continue. We’re eight months in, and we’ve already exceeded the ROI. The value proposition is there. To the degree of it, Baptist has taken a ‘lean forward, lean into’ approach to automation technology stacks, robotic automation, and other ways of helping our clinicians work at the top of their license. We cannot grow our nursing, medical staff, and allied folks fast enough. What we can do is enable and empower them so that they’re working smarter, not harder.
Bleeding edge & fast followers: “We need that balance”
Gamble: Aside from the financial component, what are the barriers that hold organizations back when it comes to automation?
Miri: Fear of the unknown. There’s fear in healthcare in general, and for good reason. You don’t want to be too forward on the bleeding edge. You want to be a fast follower so that if there are pitfalls, you can adjust. You have to have folks who have courage and conviction and strong beliefs to do that. There are a lot of leading organizations across the country, and a lot of others that follow. And that’s a good thing; we need that healthy balance. I think we’re going to see more health systems double down on that.
We’re also going to see health systems double down on natural language processing, and really leveraging voice as that modality in the future. Caregivers are working so hard to take care of people. We’ve seen the reports; physicians specifically are leaving in droves. They’re going to private equity or to the vendor side because they’re getting burned out. We have to stop this trend for the sake of the entire healthcare market.
Partnership with LECOM
People are getting older. We’re getting sicker and care is getting more complicated. And so, we need the skilled clinicians coming out of our top medical schools to stick around. In fact, we just announced a partnership with LECOM (Lake Erie College of Osteopathic Medicine) to bring the first D.O. program to Jacksonville to help grow the next generation of physicians.
We need health systems like Baptist to partner with academic institutions and universities so that we can continue to grow talent, because it’s going to take both. Otherwise, we’re going to be left with a tremendous deficit in this country — one that’s even worse than what we have now.
We already have a deficit, but we’ll have a worse one in the future. All of these dimensions add up. At the end of the day, it takes leadership, conviction, and making sure that you stand for something for your industry and for your market. If you do that, you can go forward with courage.
Gamble: I like what you said about enabling nurses and physicians to practice at the top of their license. That seems like it could play a huge role with the dissatisfaction people are feeling.
Miri: It is. And we’ve talked about it for years. Nix the clicks. Make it easier on them. Once upon a time, you could blame the electronic medical record. Now, it’s a symphony of issues that surround the caregiver. Add to that the fact now people bring their personal devices with them and say, ‘Hey, I have this app that told me this about myself.’ And so, you have to navigate all those things and make sure that at the end of the day, the patients get in the best possible care.
And it’s beyond the EMR. It’s beyond traditional X-rays and film. It’s beyond all these things. How do we encapsulate and envelope our caregivers in a way that they feel supported, they feel empowered, and they’re not having a chart at 11 o’clock at night because they’re so far behind.
Side by side with clinicians
Nobody wants that. And so, we spend a lot of time side by side with our caregivers in the field of care asking, what are you doing? How can we help you? How can we take it from 15 clicks to one click? Or how do I eliminate some of these technologies that just aren’t helpful at all? That takes time. And that’s another encumbrance because sometimes the rule is: don’t rock the boat. If it’s worked for so many years, why change it? We have to change that dynamic. That takes courage.
“All about intangibles”
Gamble: When you’re talking about this type of change, I imagine it’s important to have buy-in and support.
Miri: That’s right. It’s funny; I was giving an interview to our local news station with our Moxie robot. We were in the lobby at the Children’s Hospital, and a 5-year-old boy walked off the elevator with his mom. He looked at the robot, walked up to it, and gave it a giant bear hug. It was completely unprompted and unscripted.
And I thought, wow, that’s cool. It’s all about the intangibles. I didn’t bake that in. I didn’t bake patient satisfaction into any ROI calculations. If you stop and think beyond what’s in front of you on a piece of paper, or beyond working at top of license and these things we want to achieve, there are intangible calculations and benefits.
If you’re taking a paused, measured approach, good. But just consider the opportunity cost of what’s going to happen and what you could be doing for your local community.
“Is this good medicine?”
Gamble: It makes me think of discussions we’ve had about innovation and how there needs to be a strong focus on solving an actual problem and meeting an actual need.
Miri: That’s exactly right. It’s about starting with the why. Why are we doing this? Not what are we going to solve, but why would we even do this? There was a saying at UT Austin that I’ve adopted: Is this good medicine? Just because it’s a good idea, doesn’t mean it’s good medicine. You have to understand that before you can innovate.
Also, innovation isn’t something you can buy. It drives me nuts when folks think you can just buy whiz-bang tool and that’s being innovative. That’s not innovation. That’s buying something. There’s another saying I learned when I was on the non-profit side: you don’t clap for hope. In other words, you have to have a definitive why, you have to want to do it, and you have to have the courage to ruffle some feathers.
The innovation “seesaw”
Not everybody will get on board with innovation because a lot of folks are very comfortable being in their box doing what they’ve always done, and that’s okay. And so, how do you accommodate those folks so that they don’t feel left behind, but instead feel supported and anchored, while also having innovation to change the whole dynamics. If you find the right balance, like a seesaw, it’s actually a fun thing to do. But some folks go so hard with innovation that the seesaw gets off kilter. That’s not going to work. And so, then you go the other way, which is, ‘I don’t want to do this. I’m going to stand still and be afraid of my own shadow.’ That doesn’t work either. You have to find the right balance and you have to be able to evangelize us in a way that wins the hearts and minds of all.
Leveraging data to “do things smarter”
Gamble: You mentioned people bringing in apps before. The whole concept of harnessing data to improve outcomes and improve patient experience. Is that an ongoing effort for you?
Miri: It is. To answer the question, yes, it’s an ongoing strategy. Data and data lenses — that’s is table stakes these days. If you can’t understand your data, I don’t know what you’re doing as a business. That’s the day-to-day function. Then there’s the extrapolation and the decision science around how do we crack the walnut better, faster, cheaper, smarter? How do we think differently? Can we use data like a PivotTable in Excel? How do we pivot this data in a way that helps us see it differently; in a way that we didn’t think about before?
For example, our CLABSI (central line-associated Bloodstream Infection) rate may be dropping. Or our LWBS (left without being seen) rate in the ED may be dropping. All these things are good. But when I combine those data sets with these data sets, how do I help the folks in the ED who could become LWBS or leave AMA (against medical advice)? How do I give them technology to make sure that they’re taken care of and seen effectively, so that they’re not waiting on a stretcher to be seen because we have an overfilled census? How do we do things smarter and empower our business leaders to think differently?
That is something I think some folks in the healthcare industry are just now realizing this — outside of academic medical centers, which have done this for a long time. They’re now able to extrapolate that data and start applying it to the real world, and to the business. And so yes, we’re taking care of business; we’re seeing patients. But we’re also using that data for the future in a way we’ve never done before, and restructuring service lines and affect to make sure we’re not just providing the best care today, but also tomorrow.
“This is a pivotal year”
Gamble: When you look at 2023, what do you hope to accomplish, on a broad scale?
Miri: In general, we’re looking to truly transform into a modern, agile, 21st century department. But the problem with healthcare in general is that it was built in the 20th century with a very waterfall methodology. To flip that on its head takes a long time and it takes a lot of fortitude.
We’re on that journey. We are doing a lot of things in a very agile manner and we’re leveraging data in very unique ways. I think this is a pivotal year for all of healthcare, including Baptist, where we need to look at ourselves in the mirror and ask, what do we want to look like 7 quarters from now, 10 quarters from now, and 15 quarters from now. It’s an iterative strategic planning cycle where you’re continuously reassessing.
You have to ask yourself hard questions, like: what are we going to stop doing? What are we not going to not do? A lot of times in healthcare, there’s a reluctance to let the past go. For example, you have that old piece of junk system sitting in the corner doing whatever that’s accessed once a year. And you don’t want to turn it off, so you keep paying for it. Why?
You have to have courage and conviction to ask those hard questions. We’re in that process now. I’ve thrown the challenge to my team. I want to be out of our on-premise data centers in three years or less, bar none. Now, that’s aspirational. I know we’ll always have some local, onsite PACS images and local survivability, because we live in hurricane alley. But outside of that, 99 percent of the environment needs to be in the cloud. It should be like an electricity bill. I need to get down to a unit of service that’s measurable and monitored so that we can be effective.
To do that, all these other pieces beneath it have to be in place. You need to have observability and site reliability engineering in place to make sure that as I make that transition, I don’t lose any of the uptime, availability, statistics or resiliency that’s baked into my infrastructure. The days of healthcare being like the dinosaurs are over. And if you as a CIO or chief digital officer can’t get with the Joneses, you’ll be finding a new job soon.
Gamble: Great point. I think the holdouts are going to start to see that digital is not just a buzzword.
Miri: We’re way past that. If you look at the CEO forums and what the American College of Healthcare Executives and other organizations are teaching our CEOs, it’s that digital is the future. And guess what? They’re going to come back and ask you, ‘how are we going to do digital?’ If you don’t have a conversation with them and with the board, you’re finished.