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Fixing the Broken Healthcare System: How Design Principles Can Help
We have talked a lot about healthcare on this podcast, and we have heard a lot of good ideas for making healthcare better, but sometimes it isn't about fixing the one big thing, but the thousands of smaller things that are broken.
Hey everybody, this is Chris Brandt, here with another FUTR podcast.
Today I have with me Dr. Craig Joseph, author of "Designing for Health, the Human Centered Approach", and Chief Medical Officer of Nordic Consulting Partners that helps healthcare organizations improve their processes to make the people they serve healthier.
So let's talk with Craig about what needs fixing in healthcare, and what inspires him.
Welcome Craig
Nordic Consulting Partners: https://www.nordicglobal.com/
Designing for Health: https://amzn.to/44sSRxX
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We've talked a lot about health care on this podcast, and we've heard a lot of good ideas for making health care better. But sometimes it isn't about fixing the one big thing, but rather the thousands of smaller things that are broken. Hey everybody, this is Chris Brandt here with another FUTR podcast. Today, I have with me Dr. Craig Joseph, author of Designing for Health, the Human Centered Approach and Chief Medical Officer of Nordic Consulting Partners that helps healthcare organizations improve their processes to make the people they serve healthier. So let's talk with Craig about what needs fixing in healthcare and what inspires him. Welcome Craig. Thank you. I'm excited to be here. I'm excited to have you because I think this is such a timely topic, not, you know, the least of which of me recently being hospitalized for a bit. But, um, it was, it was an interesting perspective, so I'm really excited to talk to you. But could you give me a little bit of your background and, you know, like how you came to write this book and, you know, what you're up to?
Craig Joseph:Before I do that, let me just compliment you on Your, um, doggedness of making sure that you, you know, really understood what's going on in healthcare by getting admitted to the hospital. Takes a lot, takes a lot for someone to really investigate. You need that dedication. Yeah, really? You've gone above and beyond and I want to, I want to call that out for your audience. All right. A little bit about me. I'm a, I'm a pediatrician. I practiced primary care pediatrics in the Detroit area for about nine years and then kind of made a big switch in my life and, and moved to Madison, Wisconsin to work for an electronic health, health records vendor. So this is a company that, that makes those EHRs that your doctors either love or hate, but, but mostly hate, let's be honest. Um, and so that, that was kind of a big switch. It wasn't as big for me as a lot of people thought because my undergraduate degree was computer science. And so I was pretty comfortable kind of in that, in that techie world, but it was the, you know, really was kind of a good opportunity that I couldn't pass up and it, it did kind of change my career trajectory because since then I've been helping out in one form or another, hospitals and healthcare systems with the technology that they're. doctors and nurses and, um, and clerks and, and billing folks and scheduling folks and patients now even, even use. And so it's, uh, it's fun. It's, uh, every day is a little different and, uh, I like solving problems and making it easier for people to, uh, become healthier.
Chris Brandt:Well, so you've, you wrote and here's, here's the story. Here's where the plug comes in. Uh, designing for health, the human centered approach, which is really interesting. So I've been reading through it and I like the, um, you kind of have little kind of case studies at the end of each chapter, which are really, you know, like they help, they help you really visualize the problem, which is, which is interesting. But, um, so you wrote this book designing for health, which is I see a lot of parallels, um, to another book that I know it was very influenced, influential for you. And, you know, that is sort of the psychology. It was when I read it, the first time was the psychology of everyday things. And now it's the design of everyday things, which is just an absolutely epic book. And, um, you know, had, had, had a profound impact on me, clearly had a bit of an impact on you as well. Um, could you tell me, talk a little bit about like, How the book came together and like, what, what you wanted to communicate.
Craig Joseph:Yeah. Yeah. So the, you know, you're, you're referencing the book by Don Norman. Uh, the, the philosophy of everyday things and subsequently the design of everyday things. And, um, the cover is a, uh, a pitcher, uh, like a, you know, a coffee pitcher. picture or picture of water, but that one that is impossible to actually use, uh, because if you were pouring it out though, the water would be falling everywhere in addition to coming out of the spout. Um, and one of the things that Don Norman talked about early in his book is doors, the design of doors. And this is, this really kind of opened my mind to the concept of design. I always thought of design as. Interior decorating, like, you know, this color goes with that color and it would be cool if we made this room bigger or change the door. Um, and I have no skill set there. Um, so I'm still in awe of people who can look at this blank canvas or even a filled canvas and re, you know, come up with the concepts of how it can work. Um, but Don Norman talked in one of the beginning chapters of his, of his first book about the design of doors. And one would think like, there's not a lot probably to talk about a door. It's got a hinge and maybe a doorknob. And, um, but he showed with, with real world pictures actually of doors that are poorly designed. And, um, once you kind of understand what a good door is versus a bad door, your life has changed now because you're now judging every time you walk in or out of a room or a building. And, um, I, you know, my number one sign that a door is poorly, it's poorly designed is that there are instructions on the door. As to how to use the door. I shouldn't need instructions to use the door. So if I see pull or push, probably, probably a poorly designed door. Um, and, and the worst case is when you see it with a little sticky note. Uh, cause then, you know, it's a bunch of people who tried to pull when they were supposed to push or vice versa. And, and, uh, so yeah, doors should just work and we should know how they work and just inherently understand if there's a, if there's a, um, a doorknob, uh, or a, you know, a pull bar. I'm, I'm supposed to pull on that. And if there's a flat metal plate, I'm supposed to push on that, right? Door will open in front of me. Um, and, and so the, the impetus for writing the book with my coauthor, um, who's smarter, but not as good looking as I am, um, was to really say like, Hey, there are some design principles that, um, we all should understand basically how humans world around us, and oftentimes, especially in healthcare, but probably in all aspects of our life, um, we wonder why people aren't doing what we want them to do. Sometimes it's we, people are smoking and we don't want them to smoke. It's not healthy. Um, but it's not just patients like we want doctors to order this medicine, but they seem to always order that old medicine. That's not as. Useful now or cost a lot more and is no, no more beneficial to the patient. Uh, and so, you know, we wonder why don't people do some of the things that we, we authorities. smarter people, people with more experience want us to do. Sometimes it's not because we don't agree with the thoughts. It's just that it's the system in which we're living is designed to help make it difficult for us to do that thing. And so I've, I've gone around the country and a little bit around the world and, and seen times where we're like, Hey, we're, we're wondering why the doctors won't use the order set. Or we, you know, we're wondering why our nurses won't document this thing the way we want them to. And when you dig down deep into it, you're like, You've made it complicated and difficult to do that. So it shouldn't be shocking that people don't do that. They find workarounds to it. Now, again, I'm not saying that, um, you know, everyone needs to do everything that they're told far from it. I'm the number one example of not doing everything I'm told. Hopefully by my boss is not listening to this. Um, but you know, when we want to kind of do the right thing and you've put roadblocks in our way, uh, that's not a good idea. And that's the, that's really the premise of the book. Hey, just kind of understand these basic concepts of how people think at a, at a 30, 000 foot level and then intentionally. apply those to your next project or to your next software, uh, integration. Um, and you know, kind of think about it instead of doing what we often do, especially in healthcare. So you say, Oh, we're putting in some new software for, or we're developing a, uh, a new building for cardiologists. Um, how should it work? Oh, I know let's ask the chief of cardiology, the most important person in cardiology at our organization. Well, that's great. Except for that chief has been practicing usually a very long time. That chief, um, hardly sees patients typically because a lot of their time has spent administration again, understandably so, um, that chief usually has minions below, below them who kind of, uh, queue up everything and make everything perfect so that they can just spend their time doing, you know, quality things that they think are really important. Uh, like not documenting the visit or ordering things. And so oftentimes we, you know, in that, in the healthcare system, we, we ask people how things should work, but we ask the wrong people.
Chris Brandt:Right. Right. Well, and you remember, like you had an example in your book of like, I think it was you at taking your son to the doctor with a headache and, you know, they have this, you know, pre filled, you know, this list of all these potential ailments to check off and she just goes right for the other box and just types it in.
Craig Joseph:Well, she, she, yeah, so, um, yeah, I was taking my daughter actually to a child neurology clinic at an academic medical center, right? And, um, and, uh, the, the medical assistants or nurse, whoever it was said, you know, why are you here? And I'm, I'm looking over her shoulder as she's typing in the computer, uh, because the software that they're using was the software I was helping to design and implement and the company that I worked for. So I was very curious as to how she used it. How's it working
Chris Brandt:out?
Craig Joseph:Right. You know, I want to know that. And, and so I'm watching her and I said, you know, she's, we're here for headaches. We want to be evaluated by the child neurologist for headaches. Yeah. Neurology headache. I
Chris Brandt:mean, you'd think that'd be like a common thing.
Craig Joseph:She's got a list of 50 common diagnoses and headache ain't on that list, right? And and so she goes right to other and then goes to a free text box And I so I said, do you not see a lot of patients here? This was a this was a you know, kind of a stacked question Um, do you not see a lot of patients here with headaches and she goes? Oh, no, we see a lot of patients with headaches. I said, but the system was Does the system was not, doesn't include headache as a common choice. And she went, no, and just went, you know, went about her business, not knowing, not knowing that we could easily, they could easily change that. And right. You know, and so, um, it's just one of those things where I'm not sure how that got missed or, or. Um, you know, that was a chain that was a failure in multiple areas because I did, I asked her, how would you, how would you make this recommendation? How would you call this out to the bosses so that they can fix this for you? And she had no idea. Um, which was another kind of design flaw, because we all know we're going to make mistakes. And so we should make it easy to get feedback from people. Not all of it's going to be great, but. Much of it will be and, uh, um, that was a fix that would take 30 seconds if someone just knew about it. So, yeah, that was, that was fun. And I tried to put those little
Chris Brandt:scenarios in there. Yeah, I like, I really enjoyed those. Those are fun. Those are fun little, you know, anecdotes that, you know, just really drove home the point. I mean, and I think it's interesting, you know, cause it's like, you know, going back to the, the, you know, psychology design of everyday things, you know, there's, it talks, you know, I can't, you know, Open the door without having that same, you know, like evaluation, you know, it's the vertical bar. I'm pulling the horizontal bar I'm pushing, you know, like all that stuff when I get it wrong. It drives me nuts now, you know, it's nuts But another thing they talk he talks about in that book is, you know Sort of like decision fatigue and things like that and sort of like the cognitive errors that people make and that's kind of like what? You're talking about here. I feel like you know, cuz it's like she's so used to being in a broken system She just assumes everything's gonna be broken You You know, and that there's no way to fix it and that she has no agency, right?
Craig Joseph:Correct. Correct. And, and often you're right. Often, often you're right. Um, and so you'll find that, uh, um, and, and this is again, if you don't see a well functioning system, it's really hard to envision it. Um, it's, it was hard when you just had horses to envision a car, you couldn't ask, you know, what would you, what would you want? I'd want more horses. That's what I would want. Um, You know, you, you can't envision that. And so, you know, same thing with a, uh, uh, a help desk system. And, and so, you know, I've certainly seen that where, uh, it's difficult. We make it difficult for people to give us feedback. And then when they give us feedback, we ignore it or. Or worse yet, we take action on it, but we don't close the loop. And so the person that made the suggestion doesn't know that we're con we're considering it. And we're actually, you know, operating off of that, that change and making an improvement. And so, you know, adding transparency to that, that, um, that system really makes a big difference. And I learned that when I was on the software side, uh, when I worked for a software vendor, because they had a homegrown, Helpdesk ticket and it freaked me out when I first saw it. I was, I was, I was concerned, um, and I, I've told the story many times where I was maybe, I was maybe at the software company a week or two. And again, this is, It's coming from a guy who had just finished practicing medicine for, you know, nine years. Now he's working with a bunch of, uh, small young children seemingly, uh, at a software company. And, um, uh, I, I go to the, uh, to the restroom and the door is kind of, is closed and there's a paper sign someone wrote and said, um, uh, one of the toilets flooded and it said help desk ticket submitted. Okay. Okay. And I literally thought I was being punked. Like, I thought they were making fun of the old guy. Um, uh, and I'm like, help desk ticket for, uh, Bathroom that kind of flooded or overflowed or something. Um, but the culture of that organization was, and this wasn't actively happening, right? So it wasn't like the water was still coming. It had stopped. It just needed to be cleaned up and plunged or whatever. Um, they, they, the culture was we submit a help desk ticket for everything. But, but the, the difference was, um, they, they did a lot of things that were really smart from a design perspective. One is they didn't require you to give information you didn't know the answer to. So oftentimes we see these stop signs on, on, or, you know, we're not allowed to go. There's an asterisk next to that, to the box. Right. And you must put something here or you are not permitted to go on to the next step. Right. And, and oftentimes people don't know, like, I don't know what the right answer is here. So, um, they'll do what I do, which is put a period. You want, you wanted something, okay, here's your dot, or I'll put, I don't know, or I'll put something that won't help be helpful to you. So they didn't require any of that. They just basically said, the more information you give us, the faster we're going to be able to respond. The other magic thing was transparency. When that, that ticket got submitted, I could see where it was. I could see which employee was sitting with that ticket. Um, Right. The unfortunate toilet
Chris Brandt:fixing employee.
Craig Joseph:Well, that one was pretty straightforward, but there were others where you're like, I'm having a problem with my laptop. Like is that a, is that an email problem or is that a hardware problem? I don't, I don't know often and um, and do I submit it to this section or that section? And what you could see was I would submit it to the wrong place and instead of them sending it back to me saying like, this is not my problem, they just forwarded onto the right place. Right. And, and like, that's pretty, that's a usable system. Like, yeah, I'm not the expert in sending this to the right place. I'm sorry. I do it infrequently. I really don't want to learn how to do it correctly because I probably won't have to do it again for three years. And that time I'm going to forget it anyway, so might as well just fix the problem for me instead of, you know, it's one of those rare instances where I do want just the fish. I actually don't want to know how to fish. Um, so some of those, like, you know, um, if you make it easy for people to give you feedback. They will give you feedback if, if they see that you're taking action and, and, um, or being transparent about your actions. And so again, oftentimes, um, it's not that I want, you know, if I, I told you something, there's a process that we do and it's really dumb because we shouldn't have to do this and no one cares. And I'm still forced to ask this question of every patient that I admit, um, sometimes there is a reason. Yeah. Yeah. Sometimes it's may not be a reason we agree with, but the government or the insurance company or someone says there's a rule. And so getting back to me as the issuer of that, you know, request and saying, Hey, we agree with you. This is really not, um, helpful. However, we can't get rid of it because of X, Y, and Z. And so we just wanted you to know that, like that is, uh, that is a great interaction. And now I know I should blame the government, not my IT, not my IT leaders.
Chris Brandt:Exactly, exactly. It seems like there's a lot of just the basics that haven't been covered in healthcare. And, and like, you know, you're, you're kind of, uh, putting forth that. There's a lot to be gained by fixing some of these small things, but, you know, obviously there's some challenge with that too, because, you know, when you start applying changes, you have to think it, you know, broadly to how that's going to scale across, you know, the country or even the world. Right. And, and so, um, you know, You know, I think that's got to be, you know, kind of a challenging, you know, place to be like, how do you, how do you solve these problems on a, on a larger scale? But maybe they don't need to be, maybe they, you know, just act locally and, you know, it'll, you
Craig Joseph:know, I think, um, I was, uh, uh, I was going to use the word counseling one of my children, but I don't think you ever really counsel your children. Maybe it was yelling. I don't know. But, uh, my kids are, are, uh, Maybe for me You know, I was I have a my children are older and and so one of them has her own health insurance now She's off of my health insurance plan, which is amazing and scary at the same time And she was struggling I she was struggling with some stuff and I happen to know a little about health insurance and the way Health care system works in the United States and I I ultimately said to her I think you just need to understand that no matter what you do. It's wrong, right? Um And she's like, how could you possibly say that? I'm like, I am much older than you, which is how I can say that, you know? Um, she's like, well, tell me is it better to do A or B? And I'm like, I just do one and chances are excellent, it won't work. And then you go to option B. You know, do I call the doctor's office when I this, I get this bill that I think is wrong, or do I call the insurance? And my answer is, yes. I don't know. Uh, it doesn't, whoever I call in my experience, I needed to call the other one first. And so just, it's just random. Um, yeah, you know, decision, uh, um, uh, clinical decision support is there for physicians and nurses and in healthcare specifically to, to, um, to in some ways, uh, alleviate some of that. Um, That, uh, the, you know, the, the concept of, of having too many decisions to make being kind of, uh, um, anxious by decisions. Um, you know, Oh, I, I believe it was, uh, president Obama who had, um, his clothes all like picked out for him. Like he did not want to waste time thinking about what suit he should wear. So he just pawned that off on someone else, right? The decision fatigue, he just. You know, I got a lot of decisions I'm going to make as few as possible and let someone else come up with this. Um, and I think that's true a lot with physicians as well. And so, you know, we talk about making it easy to do the right thing. Again, like pretty basic design principle, make it easy to do the right thing. Now that's actually something that you can implement as I, and again, as I go around the United States dealing with very sophisticated and complicated healthcare systems, oftentimes they say, well, that's more, that's, you know, that's not as easy as you say. And I'm like, no, it's actually super easy for me to implement, uh, making it easy to do the right thing. The hard part is you telling me what the right thing is. So, so most physicians, I would argue who are admitting a patient to the hospital for community acquired pneumonia are not infectious disease experts. They're, you know, primary care docs or hospitalists who deal with a wide range of like, Hey, I just want to know what's the best antibiotic for right now. for the hospital that I'm in, you know, cause you go from different states, you see different, um, types of bacteria and viruses. And so, so that's a decision that ultimately most of us will say like, Oh, I'm, I'm happy to go with the flow, you know, tell me what the right antibiotic is and I'll prescribe it. Well, that's a decision I probably don't have to make actually. I really don't want an answer to that question. What I really want is a set of orders that I can open up called community acquired pneumonia, and it'll have all the things that I'm generally supposed to do, and I'll agree with most of them. And so, you know, having the antibiotic or a small selection of antibiotics there, um, and then defaulting the, the right answers, right? Why should I have to click on one of the antibiotics? Why don't you click on the antibiotic that is the cheapest? Um, you know, and so it's already defaulted in, so I don't have to make, that's a decision I don't really need to make. Now, my patient's allergic to that class of antibiotics. I have a decision, right? Then I have to change something. And so, so there are always reasons not to do the right, the quote unquote right thing. Um, but I'm going to do the right thing most of the time because I want to. That's why I went into healthcare. That's almost why most of us. kind of live in society. We want to do what the right thing is most of the time. Sometimes we disagree for a good reason. Sometimes we disagree for a not good reason. Um, so we still have that agency. We still have that choice. The, the ability is always there to make other decisions, but make it easy for me to do the right thing. There was a lot, there's been lots of research that says, Hey, when, when you started a new company, uh, there's two ways of getting us, of getting you into the retirement program, the 401k, right? One is to opt in. Which means you're not in unless you tell us you want to be in. But what happens if we flip that upside down and say, well, we assume you actually want to be in the retirement, in the 401k program, we're contributing as the employer, some money to that. So it's your money plus our money. Um, we're going to assume you want to be in it unless you opt out of it.
Chris Brandt:Yeah,
Craig Joseph:right default choices default choices make it easy to do the right thing Yeah is another way of saying that so absolutely, you know, you're the uh, more sophisticated term is choice architecture um, you know, uh, we we the grocery store uses it when they put the food that they want you to To buy it milk in the bag level Yep, we, we want the, we want stuff you want to buy at the eye level, stuff that we're a little less concerned if you buy it or not. Maybe the margin is not as great. That's going down lower or it's going further back. Um, these are, these are decisions that kind of are to some extent made for you. You think you're making all of the choices, but yeah. They're making it easy for you to do what's the right thing for them. Yeah, maybe the right thing for you, but definitely the right thing for them. So yeah, some of these little things again, making it easy to do the right thing. I've seen, you know, I see order sets, again, sets of orders that doctors use for things that they do commonly or actually less commonly.
Chris Brandt:Yeah,
Craig Joseph:and just say, hey, I, why are there multiple choices here? I don't know what the right answer is. I'm just gonna pick. All right. Well, it'd probably be better for the expert, the infectious disease specialist to pick for me. Tell me like, well, most of the time for most patients for this diagnosis, this is the antibiotic that you want to use. Terrific. I'm not going to argue with that. Or pharmacy.
Chris Brandt:Pharmacy, you know, that's another discipline that you don't, you know, is I think underappreciated in the world because when you're in the hospital, you know, pharmacy can add a lot to the treatment.
Craig Joseph:Exactly right. And we talk about team based care now, um, which is different, right? And, and the, and, um, 50 years ago, uh, the doctor was at the center, the doctor was the son and everyone, including many would say the patient, rotated around them. Um, and, and, uh, we're hopefully smarter now and know that, well, the doctor might still be the captain of the, of the ship, but you still need a lot of people to, to run that ship. And so making sure that nurses and pharmacists and respiratory techs were are all, um, kind of on board. We're all communicating, letting them make decisions that they can make that because they're smarter than we are. Um, I, I remember vividly being told once, uh, when I was a pediatric resident at a children's hospital, Hey, we need you to go draw blood from this patient. And so why I don't normally. Get that kind of request. What, what, why do you want me to do that? Well, the phlebotomist who does it all day, every day was unsuccessful.
Chris Brandt:And
Craig Joseph:I'm like, this makes no sense whatsoever. Unfortunately, the buck did stop with me as the, uh, as the resident. Um, but it's just one of those things where you're like, Hmm. You know, we see this sometimes, uh, where a pharmacist has to call and say, Hey, Hey doc, did you know that this, uh, medicine you prescribed is not effective at this dose or are you trying, they don't, hopefully this doesn't happen very often, but you know, are you trying to kill the patient? Cause that's those. Yeah. That you wanted was very high and we, um, you know, much of the time there's just minor things. It'd be great if we can just kind of work as a team and like, yes, no, I, I did not mean for that to be, I did not mean for that pill to be squeezed through the IV tube. Yeah, I was not trying to kill my patient. You know, I made a mistake and thank you for calling me, but just fix it. Uh, and um, I think we're getting better and better at just fixing it, you know, kind of bypassing the, um, the, the kind of step of, well, we wanted to make sure you weren't trying to kill the patient.
Chris Brandt:Right. Well, and, you know, and on that, I mean, um, there is medical mistakes does cause a Do create a lot of bad outcomes and, you know, when I look at the state of health care right now and physicians and, you know, having just spent a lot of time talking to physicians and sort of hearing some of their pain points, you know, in preparation for this, because I, you know, I did, I did my deep, deep, uh, you know, learning on this, um, you're the man, you know, they're being squeezed a lot. Cause you know, like, um, you know, You know, they, one, there's not enough doctors to go around because there's not enough residency programs. There's not enough residency programs because some residency programs, like internal medicine and things like that, are underfilled. Whereas some of those, like the specialty ones that are, you know, more, pay better, are, And, you know, and a lot of it comes down to like procedures and whether or not you can do procedures because there's a very straightforward way to get paid on procedures. But, you know, the doctors who have to do more, you know, the research and the brainstorming and things like that, you know, there's not a procedure code to go along with it. So they, some of them are struggling to make ends meet. And, you know, like internal medicine, the, the, the. primary care physicians, you know, it's, it's tough to, to, you know, on them because they don't have those kind of procedure codes to put in, you know, they're not doing a lot of stuff. So they're, they're, they're literally struggling to pay their bills in some cases, you know, and so, you know, The way they fix that is like, you know, we'll get these immediate care centers. So we'll take some of that load off of you. And then, you know, you'll have more time to do this, but then it's like all this insurance billing and all this other, you know, non medical stuff that they're doing. So that by the time they get to see a patient, they have such a limited amount of time. They're stressed out in their minds about doing it. And, and so like, you could see how easy it would be to make mistakes, which I think really reinforces what you're doing in that, you know, Taking away some of these barriers to making the right decisions. is going to be really important in this kind of context because it helps not make those kinds of mistakes. It helps them get through some of the, you know, unvaluable kind of time that they spend faster.
Craig Joseph:Yeah. You, you've hit the, uh, the nail on the head, um, with some of our payment schemes here in the United States. Uh, and certainly we're making, we're endeavoring to make that better. Uh, but it's, difficult and it's slow and there's lots of constituents that want to protect the, their piece of the pie. But yeah, the, you know, there's a, there's a good question of, there's a lot of things that physicians do that one wonders why they do it. And, and so, you know, we talk about, um, uh, public health screening, you know, um, uh, every, you know, women are supposed to get, um, um, mammograms now blanking. Thank you. This is what happens when you're a pediatrician and never order mammograms. Um, women should get mammograms and, and, um, uh, you know, there's lots of other things. Everyone should be getting, uh, colonoscopies or at least checking for colon cancer screening, uh, one way or another. And often that doesn't happen. And, and, um, one reason is, well, traditionally it only happened when you came to visit the doctor. When you came to visit us for whatever reason, you had a sore throat or your, is your annual physical, we would look and go, Oh, you haven't had a, you haven't Uh, colon cancer screening for a while, um, you know, every 10 years you should be doing that or whatever it is for, you know, that and, and the, the question a lot of people are asking now is, well, why, why is that? Why is it that we need, um, to only do that during an office visit? Why can't we use our, our fancy electronic health records to look for everyone who's in our system who's between this age and this age and hasn't had this screening and so long and then send them Not only a card because that's what we get a lot of is like, Hey, here's a, here's a letter telling you that you need this. Why don't we just order it? Why don't we just order it? And in fact, why do we need a physician? As you just pointed out, they seem to be in high demand and should be working on other things. Do we really need a physician to order this test? Certainly we need a name. And we need to know who the result is going to go to for sure. But, um, can't the healthcare system just kind of take responsibility for ordering it and making sure it's, it's going through. And so there are some things where we kind of have still that kind of paternalistic attitude of, well, the doctor knows if you need a colon cancer screening. Yeah, well, the doctor knows and so does this, uh, you know, junior high student over here who can read that you need to have a colon cancer screening. You don't even need a person to
Chris Brandt:do it. You can quite just scan the records and automatically send it out.
Craig Joseph:Right, again, going back to that principle of making it easy. To do the right thing. That's the, you know, if the right thing as a patient is for me to get the colon cancer screening, then make it easy for the love of God. Don't make me schedule an appointment. Don't make me, you know, have to call the office for an order. Just let the order happen. Uh, you know, someone should order it and then someone should, um, uh, make it very easy for me to schedule and it should be, uh, you know, why are we not doing these things on the weekends? Why are we not doing them, um, at other times or places? Absolutely. You know, for people that are working during the day, that's a major problem. I have to take a half a day or a day off for, for that kind of a thing and it doesn't happen. And it's in our best interest. It's in everyone's best interest, uh, to get that done, right? It's not just in the patient's best interest, but certainly we don't want to spend as much money as we do in the United States. We're among the top, if not the top of all, uh, you know, advanced nations in terms of how much money we spend on healthcare. It's much worse results. It's much better. Right. With worse results. That's a kicker. So, yeah. It's better for all of us. Uh, uh, I'll pay less for my health insurance and you'll pay less for your health insurance if we can catch cancer early. Right. If we can prevent the long term of complications of high blood pressure, um, it's gonna save someone's life. That's great, but it's also gonna save all of us money, too. And that's also great. And that money can then be used for other things. And so, yeah, I think the, you know, whether we're talking about an electronic health record, or technology, or the way a hospital runs, or the way the whole healthcare system runs, there's lots of opportunities to kind of think intentionally about applying some of these basic techniques. Design principles and making things better.
Chris Brandt:And I like, you know, your perspective on it too, because you're kind of focused on the end user, you know, like the end user's perspective, right? And, you know, like you were mentioning a couple things, um, there, you know, sort of like getting the annual mammograms and, you know, like, and, and PAP. Screenings and stuff like that, you know, like when I talk to my wife, for example, she's like, there's got to be a better way to do a mammogram screen rather than just taking these plates and smashing, you know, the breast tissue in there and, and, you know, like pap, Uh, pap screenings, like, you know, taking a, a, a portion of the cervix without any anesthetic too, which, you know, is, is by all accounts, a very sensitive area. Right. I mean, you know, there's a lot of things that we just, um, ignore for, you know, certain reasons. Segments of the population that makes them more reluctant to go and do some of these things, I think, as well. So it's, it's, you know, it's kind of a combination. And then there's a financial incentive in there. It's like, well, we don't have to buy this special, you know, x ray machine that's dedicated to mammography. You know, we just want to use the one we use for other things. And, you know, and, you know, we don't want to have, have to pay for anesthetic for this procedure. You know, it's why, why would we do that? You know, so it's, there's a lot of like. Perverse incentives for, for, for everybody. But I think, you know, you're getting to the point of like, let's talk to the point at which this is happening and get the feedback from those people, you know, like being in the field and seeing how this is, applying in real life and seeing how we can make those things better, right? I really like that perspective.
Craig Joseph:Yeah. And we quote someone who talks about an innovation safari, um, uh, as a physician who's, who's taken some of his leaders, uh, at various hospitals and various companies and, and taken them to other industries, right? So, you know, In healthcare, we're kind of used to, Oh, well, we're going to go over to this hospital across the state or across the country and see how they do this thing. And that's often helpful and you can learn things, but you can also learn things by going to a factory that makes cars, um, or, you know, a manufacturer that does something and, and kind of take some of those lessons back and, and, and apply them to healthcare. So, you know, one of them, like you said, making sure you know who the user is and, and, and. make sure that you're trying to help them and to some extent that's by identifying the right user. I just, I earlier was, uh, made disparaging remarks about the cardiology chief. I apologize to, to them about that, but I stand by those remarks. Um, they're probably the wrong user to ask how a cardiology system should run. Um, but so certainly you want to find those people that you do it every day and ask them and understand what they need. However, it's not just ask them what they want and give it to them. Cause again, Henry Ford would be delivering more horses if he asked what people wanted and then delivered that to him. So you, you need to understand their problem, but then you need to, to offer a solution, which they may not even have contemplated. How could they? And so you don't need the
Chris Brandt:horses. You need a horse equivalent,
Craig Joseph:right? Oh, that's exactly right You know i've been the the chief medical information officer for a bunch of hospitals and health care systems and that just means i'm the the the chief doctor geek um And oftentimes doctors would come to me and they say hey listen I need a new order set or I need you know, this new uh Uh, functionality from, from this, this particular software vendor. And I'd say, Hey, you know, it sounds like you're telling me that about a solution. Um, I'm really not interested in hearing your solutions. I'm interested in hearing your problems. Right. So why don't, instead of telling me you need a new order set, tell me what the problem is. Oh, well, the problem is that I can't find this thing or that thing. And, and whenever I need it, it's not there. Okay, you know we could do this. Oh, I didn't know that now. I know you didn't know that that's my Your job is not to know that your job is to see patients and help them. My job is to help you Um, so I know that and so when you come to me with a problem I can help you You know point out sometimes solutions you never thought existed. So hence you would never ever ask me for right? Um, so sometimes they come with a solution and they're right, but i'd say more times than not It's not the best solution and they're happier when I Kind of intervene and try and take it back a couple of steps. And so it is important to ask users what they need or what they think they need, what they want, but it's also important to observe and then understand, well, why are you doing that? You know, Hey, we have this form. We need you to make this form into the, into the computer so we can get rid of this piece of paper. And I'm like, well, I love to get rid of pieces of paper. So let me help you with this. Why do you have this form? We've always had this form. Okay. But why, why, what, what, what, what's here that, well, we've, we just need it to go from here to there. And I'm like, well, I don't, you don't now because of the technology we have, like you don't need. So, so, you know, again, I, Hey, what's the problem this form is trying to solve. Can I solve that in a better way? Or. more often than not, it's not solving any problem whatsoever. It's just a dumb piece of paper and we just keep it around because we keep it around.
Chris Brandt:Right. Yeah. And I, I think that's, that's, that's important because like, you know, in technology, if you don't have those kinds of conversations, you get a very kludgy, Project with lots of bolted on stuff that doesn't make any sense. And then it becomes unmaintainable and unsustainable a hundred percent.
Craig Joseph:And it's, and it's just common. Like if you've done something the same way for, for decades, you're not generally, as you know, we humans are not kind of built to kind of question that, right? Well, it's, it's worked. You know, it's, it's worked and this is great, but you know, do we still need it? What, why did we start it back then? Oh, there was a rule back then that we don't have now. I, I tell the story. If you're going to eliminate that person's
Chris Brandt:job to throw away all those sheets of paper. Well, it might, but
Craig Joseph:it might, but we hopefully can find another job for them. That's more meaningful. When, uh, when I first joined this, uh, EHR vendor, I was at a, at a go live at a Major Children's Hospital and, um, they, I was called to a fight and, um, the fight was, it wasn't actually a physical altercation, but I think given a few more minutes, it might've been, um, the blood bank didn't want to send up blood. Because they didn't have a form that they absolutely needed and that's a problem. So we need to resolve that very quickly. And there's all kinds of regulations and laws about blood, again, which there should be. Um, and so the argument ultimately boiled down to the blood bank saying, we need this form with this physician's signature on it. And we never send out this, uh, blood without the, the form and this physician's signature on it. And then, uh, when I looked at the physicians, they said, we don't know what this form is that you're talking about. We have never filled it out. We have never signed it. And so, there was an impasse there. Um, Ultimately, it turned out that the unit clerk was signing this form for the last 10 years, right? And he retired? A unit clerk. No, no, no, no. We had moved from, we had moved from paper to electronic. So that, that's why this kind of had come up. Um, this form clearly, clearly held no, um, essential information because a unit clerk, uh, essentially the secretary of the floor was filling it out on behalf of the physician and was scrawling the, a physician name or something like that there. And so, you know, we were able to get rid of that form. Um, Because, you know, we were able to convince the, the blood bank folks that, uh, in fact, they were getting all the information and, um, it was coming from, instead of being transcribed, uh, from the chart by a clerk, it was actually coming from the physician. So it was a win, it was a win for all, but again, you just don't, you don't think about that. And that's, again, one of the benefits of doing that, as you talked about kind of walking around and seeing how people are doing their job, just observing. You find these things where Everyone thinks it's functioning great. And when you start asking questions, no one has answers to. It's awkward, but, uh, um, it reminds me of Jack Welch, uh, who's, who said that he, he practiced, uh, you know, someone asked him about his management philosophy and he said, I do management by walking around. Um, right. I, and again, the point is, Hey, it's one thing for me to hear what my chief financial officer thinks and my chief operating officer thinks, and they're going to continue to tell me what, what's going on. But it's very helpful for me to go to the factory floor and just walk around and ask questions.
Chris Brandt:Yeah. Tell me a little bit about what Nordic Consulting Partners does.
Craig Joseph:Yeah. Thanks for asking. So we're, um, as you mentioned that we're consulting, so we're, we're, uh, uh, Health care management consultants kind of started off just helping with one electronic health record and we became known as really having the smartest people about this one big major electronic health record that a lot of people have used and and still use. And we've expanded since then. So we Thank you. not only help with that electronic health record vendor, but with other EHRs. And then our customers were asking us, Hey, can you help us with some revenue cycle stuff? So Hey, we're, we're not bringing in the money or we think we're supposed to, you know, we're not billing the way we're supposed to be billing. And so we've got some of those expertise. And then we went outside the U S. And, and so now we're in Canada and Europe and soon to be the Middle East, but, but basically we are problem solvers. And so we look for, again, it's much more exciting for us. And I think helpful for our clients when they come to us with a problem and not a solution. Sometimes they still come to us with solutions like, Hey, we need three experts for nine months to help us, um, get down to from multiple billing offices to one single billing office. That that was a common refrain. By now. We're hearing more of, hey, we're thinking about combining our offices, our billing offices into one to make it easier for patients to get more information about their bills and to make it easier for us to manage that whole process. How do you think that should work? And so That's what a consultant does is kind of say, well, we've done this a bunch of times and we've seen it done well and not so well. We've seen the common reasons and the not the uncommon reasons for doing something. And so we can kind of bring that more global perspective to some of these questions and help out our clients again, which are typically large healthcare systems and hospital systems in the U S Canada, Europe.
Chris Brandt:Yeah, it sounds like really necessary work, so I appreciate that you're doing that. So, so like, what's next for you? I'm, uh, I got,
Craig Joseph:uh, uh, Curing Cancer, that's on my list. That's a good one. Um, yeah, yeah, then after that it's gonna be World Peace, Chris. Okay, okay, I'll take those. Now, uh, I have an idea, I have an idea, I'm not doing either of those. I mean, let me be clear, I would love to do those two things, but I feel like I am probably not best equipped to handle, um, the curing of cancer or the, um, the getting of world peace. Um, I'm, I'm actually interested in now actually something called de implementation or de adoption. Okay. And, and, um, this is, this is, uh, uh, um, an, uh, an interesting concept to me. Sometimes we find things in healthcare, that we thought were really smart to do, but now we know, uh, it's actually, there's no evidence that it's helpful or even worse. Sometimes like, Ooh, we did that thing. It's harmful. Um, I'll give you one example, ordering EKGs or electrocardiograms before patients, uh, older patients typically go for, uh, uh, any type of operation, not cardiac. So imagine you're going to get your knee replaced and you've never had a heart problem before. It's not uncommon in the United States. In fact, I'd say it's very common that your orthopedic surgeon is going to do your knee replacement Is going to order an EKG, right? And the and the and if you were to ask why why would you do that before? I have this knee replacement. I never had a heart problem. Never seen a cardiologist Well, we we want to be sure that everything's okay, and it's just an EKG and it doesn't even doesn't even it doesn't even hurt You're right. Just a bunch of sticky pads and it literally takes a minute It's a minute. I, I do find the sticky
Chris Brandt:pads very painful to pull off, so I will say
Craig Joseph:I am with you a hundred percent, but I'm, I'm, you know, trying to sell this thing, Chris. Help me sell it. Okay? Okay. Okay. I'm helping
Chris Brandt:you sell it.
Craig Joseph:And so, you know, what's the harm? It's a cheap thing. And if we, if we discover a problem before we put you under anesthesia, that's a good thing. Well, the problem is that oftentimes we discover. Lots of things, but few of them are actually clinically significant. And so what happens is, well, you know, a good chunk of the time, there's something there, but the orthopedic surgeon is not an expert. at looking at EKGs. And so they refer you to a cardiologist and then that takes time to get into to see the cardiologist and the cardiologist says, well, this is probably nothing, but we probably want to do an echo or some more expensive or invasive tests just to be sure, because we don't want to find it. And so again, sometimes Sometimes they find something but more commonly they don't and it it wastes time and money and Sometimes again you get a procedure You end up getting a diagnostic study. That is actually harmful to you. You know, oh, we're just gonna do the study We need some dye Okay. Well, you've never had died before, but now we find out you're allergic after we gave it to you and now your kidneys are shutting down. And so we're going to have to put you in the hospital again, all because you wanted to get your knee replaced. And so the question is, how do we convince doctors to stop doing these things that they've been doing for decades? Because now we know that there's little evidence for that kind of that thing that D and how do we do the opposite of implementing D implementation? And it's not as simple as, Hey doctor. Stop doing that. Um, cause we don't do that. And, and, um, it's, it's a lot easier for us, you know, inertial is just to keep going. Plus we all have stories after we've been practicing long enough. Like, well, let me tell you, I know I've ordered this EKG 8, 000 times, but let me tell you about the one time that I, that I ordered it. that this patient, you know, was going to have a hard time in the surgery. And so for that one time, um, I, you know, I want to order it now for everyone. And again, totally understand that's the way we humans think.
Chris Brandt:Malpractice insurance has gotten very expensive too.
Craig Joseph:Correct. Correct. Um, and so there, there are a lot of, um, incentives, I would call them perverse incentives to keep doing some of these things. And so that's an idea that I'm playing around with, but, um, Don't, don't tell anyone cause it's a, it's secret. It's between you and me, Chris. All right.
Chris Brandt:And all the listeners.
Craig Joseph:No, no. What? Listeners. I thought we were just having a conversation. You're confusing me now, Chris. Yes. Yes. This
Chris Brandt:is a covert operation to steal your ideas. Oh, it's working. It's successful. It's working. Yes. Well, I think it's a little harder to implement some of those ideas. It's it's in the devil's in the details, right? Correct. Um, well, you know, I really, it's fascinating stuff and I, and I want to just. You know, say go read the book to designing for health. Actually, you know, I know, you know, like there's a lot of other reasons to write books, but I thought I found, you know, some of the stories in here really interesting. And if you're interested in health care, um, you know, it's, it's, it's worth a read.
Craig Joseph:Yeah, awesome. And you can get it on Amazon if you're interested. And, um, and I'll put up a link. Yeah, that'd be great. Love for people to read it. And, um, I always am looking for feedback, but only if it's positive, Chris, I'm only interested in positive feedback. I'm very sensitive to negative feedback and I, I would be scared about that.
Chris Brandt:All right. Well, we won't give any negative feedback because the internet, the internet never gives negative feedback. It's all
Craig Joseph:positivity and love on the internet. I mean, YouTube
Chris Brandt:comments are the best. They're just a font of positivity.
Craig Joseph:It's the great humanity right there. Yes. You and I agree.
Chris Brandt:Well, thanks so much for coming on. Thanks so much for doing what you do because I think, you know, like improving the health care system is a You know, it's a Sisyphean task, but, but, uh, much needed for sure. So thank you for doing what you do and appreciate you being on. Thanks for having me. It was fun. Thanks for watching. I'd love to hear from you in the comments. And if you could give us a like, subscribe, share with your friends and all the people you know, and I will see you in the next one.