Clinician Engagement & Governance for Success

In this episode, we meet David Butler, MD. Founder and Principal of Calyx Consulting. David has a long track record of success when it comes to leading top health care organizations through the process of selecting and deploying health IT applications. His extensive experience in building efficient and effective governance processes that align strategy and operations has given him a ring-side seat and expertise in what works and what doesn’t. David shares with us his insights on what it takes to effectively engage a wide-range of individuals and teams across an organization. We also explore the changing role of Chief Medical Information Officers (CMIOs) as organizations pivot from deploying health IT to maximizing the return on their initial investment. Given his experience and humor he also offers an entertaining and worthy pet-peeve and some very sage advice.

Dr. Dave Levin: Welcome to 4x4 Health sponsored by Sansoro health. Sansoro Health, integration at the speed of innovation, check them out at www.sansorohealth.com I’m your host, Dr Dave Levin. Today I’m talking with David Butler, MD, founder and principal of Klx consulting. For more than 15 years, David has been a recognized health IT leader when it comes to deploying and utilizing health IT. He gets governance and workflow and knows how to execute with a proven ability to partner with clinical operations and IT practitioners and executives and health systems like bon Secours and Sutter health. In 2016 he started his own healthcare IT consultancy Klx partners, a (Inaudible) firm that focuses solely on HR, post live efficiency training optimization and strategic planning. He must be doing something right. His clients include New York City health and hospitals, Gutherie Krennic and my former Alma Mater, the Cleveland Clinic. Welcome to 4x4 Health David.

Dr. Dave Butler: Hey, thanks for having me on. I’m really honored. That was a great introduction you have on me ok thanks.

Dr. Levin: That that was an edited version of your introduction. There’s far more. Let’s jump in. Dave, I’m going to ask four questions and you have about four minutes to answer each one.

Dr. Butler: Awesome.

Dr. Levin: First question, tell us about yourself and your organization.

Dr. Butler: I was born to the (Inaudible) of a sharecropper Dave on the shores of silver lake and the big ones. The Wisconsin vision was religion. All right Okay. Okay. Okay. Full disclosure. Full disclosure, Dave, I wanted to be a standup comedian as a child. Watches a lot of Eddie Murphy. Ellen, Johnny Carson, or you name it, but I found the jokes would fall flat, but my grades are solid A’s, so I thought I’d become a doctor. I’m a doctor, Dave Butler. I raised in central Texas town. A little bit about me personally, central Texas town. Not Far from Waco. Yeah, I know David. Chris thing keep to wake up and now we’ve got chip and Joanna flipping the brand, right? The fixer upper, so gotta give him credit. All right. I’m the youngest of five kids. You know, we’re all in a row. That’s good and bad. The good part was that I had to ask her why she genes in the eighties before anyone else. Thanks to the hand me downs from my older brother, but the bad part was, the bad part was, uh, good luck having any hot water left for me in the shower before school.

But on a more serious note, I’m just a Texas boy at heart who lives in northern California now. My wife, like you said, two adult kids, one’s 18 computer science major daughter, 23, Nyu alum doing really cool things and I’m really proud of them. Luckily both are out of the house now, but, uh, you know, kind of playing with the house money, I guess if you say, as you said, I am trained in internal medicine, pediatrics and I’ve, I’ve been really blessed that I worked in large hospitals all over the US trained in the Texas Medical Center. That’s the universe, takes the health science center. Bakey Ba MD Anderson, memorial Hermann, Ben Top. I’ve seen so many really great things and disease process and had great mentors and things like that. And so, uh, so I think all of that helped shape, uh, you know, what you just said about me and how I’ve gotten where I am.

Dr. Levin: Well I do think you have a (Inaudible) But  I recommend you keep your day job for the right now.

Dr. Butler: I know, right?

Dr. Levin: So that’s okay, I’ve seen you, you were in very effectively  in a variety of situations. Tell us, tell us more about the work that you’re doing right now. What are you working on that’s really interesting? Really cool.

Dr. Butler: That’s a tough one because I’m an idea guy. I’m the guy that I never had a positive ideas. You know, it’s almost, I have ideas like Oprah has, yes. You know, like you get an idea of Uber driver, you get an idea of Starbucks Barista, you know what, you get an idea, a little random queue, sit next to me with your iPhone and on the plane. So I guess right now it’s so cool because I started my company about two years ago and I’m no longer locked to the corporate entities that sometimes we’ll put those ideas in boxes and keep you in your lane, you know? And that’s what I hear from a lot of my colleagues. But now with young own company, you get to kind of explore those ideas a little bit more calculated risk. And some of it’s really cool. The things that I’m looking at working on right now is just, I really love what we do as a company, as Kaylee’s where we, uh, we get calls when some large companies may implement an Emr, usually a year or two years later, they can’t quite figure out why the investment is not mass being maximized or they can’t figure out what the white noise from the signal, you know. And so I liked it, we liked to go in and to help them dissect out those things. And it’s really interesting, exciting. But more importantly, one of the one service lines that we’re really looking, looking at working on is how do we address this physician burnout epidemic and a in a cost effective way. And as you know, like, you know, a lot of, there’s a lot of talk around the physician burnout epidemic, but I just find a lot of the recommendations, like the yoga, mindfulness, those are great. Those are awesome. I think you can do it, but a lot of my clinical colleagues are still seeing 25 a day. They are in medicine, they are the front line of this thing. I think what they’re looking for is like what can we do Monday? And so that’s the kind of what we’re working on now. It’s a bit in the, it’s a bit, uh, we still let the drawing board on it really close to it, bringing out something that I think will be really, really cool. So that’s what we’re working on right now.

Dr. Levin: Well, Dave, you are definitely an ideal guy, but one of the things that I’ve always admired about you is your practical ability to get things done. And so tell us a little bit about, you know, as your approach in your former roles are in your consulting role, you know, how do you marry up that vision with the steps that you have to take to actually affect change in the world?

Dr. Butler: That’s a great question. And I think that I have been really blessed over the years to have really good mentors. And these mentors have been everything from a lean six sigma that they’d been CFOs, CEOs, they’ve been Mbas and they’d been a bit more outside of the healthcare vertical. And as I talk with them about some of the challenges that we have in healthcare, it’s like, oh, we did that in the eighties and nineties. That’s just what the Erp, I was like, what’s an ERP You know? And so those are some of the things I think that I’ve learned from others to how to uh, take a large complex problem, break it down into its pieces. Start, focusing on those tactical pieces. But first you have to deal with the people processing technologies of it. All. Right. It was really surprising as a doctor, you know, we were trained to, right, you know, Steve Patients and make them decisions, evaluate all the data and then start treating that patient. And the, I was a hospitalist by background mainly. So it was a write the orders and those orders came from me. It was, there was doctor’s orders. They want suggestions, they want to thoughts, they want ideas at night after a brandy shot. You know, it was orders. Meaning if I wrote 10 orders the next day, we would expect that 10 things right or a little bit more, would it be done for that patient? Right. And that was a mentality that was really hard coded in my residency. But then as you start thinking about collaborative work, doing really great things, you have to use a team. And so breaking out of the traditional cowboy as the tool Gawande calls it cowboy mode into the pit crew mode was something that was really a bit difficult for me but wasn’t a big leak. You know. And then once I started learning how to leverage the groups and teams and people around you and take ideas, even though you may not have come up with them or ownership, I felt like that’s when it really took off on me, you know, bring in people that were smarter around me, that were smarter than me. Uh, and I think that was, when it really took off and think could really gets things done. And uh, allowing folks to be innovative and not telling them the answer. What I think you know, but just say, Hey, what do you think about we should do about x, Y, and z? And I’ll find it, you know, with the right folks around you that come up with really innovative things that you can encourage and support and it only makes them more innovative next time. So I think that’s been my secret. Is this bringing smart people around me? Do you have an another division or let them really know what the problem is we’d like to try to solve, but trying not to be too prescriptive and put them in a box, especially in the informatics route. Right. You probably know that better than I do Dave.

Dr. Levin: Well, if that makes sense. It makes perfect sense. It’s an ask, don’t tell approach. And you know, you mentioned what I call the iron triangle of people, process and technology. And I think for myself, as I began to do this work in the early stages, if I was aware it was a triangle in my mind, it was a very skinny, narrow triangle. And most of it was about technology. I learned in the early going of HER implementations about the importance of workflow process and process redesign. And I think you and I have spent many hours talking about things that were fixed and things that weren’t fixed as part of that. What has become increasingly clear to me, particularly in the last few years is the people part of it. And I think you spoke to that really well and I wonder if you agree with me, I’ve seen a lot of our colleagues start in these kinds of roles with a kind of technical mindset and and associated behaviors and then they grow into actual leaders and it becomes less and less about the technology and more about the way you organize and lead other people to identify and solve problems.

Dr. Butler: You’re spot on. You know, I think early on these things are really technical and the pioneer, the early doctors and you know the early doctors that took on these roles and, and the healthcare systems were the techie docs, right? Cause they were just volunteer for, they were excited about it. Right? Is that right?

Dr. Levin: They were happy to be down in the engine room. Right. They were like, they were engineer(Inaudible). Exactly right.

Dr. Butler: They were just amazed at some of the bells and whistles and all that. But I think gradually some of them, not all of them, you know, they can sometimes be detached from the regular army or the 80% of docs that are really not that interested in the technology. When I could, they’d come in the room, they hit this light switch, they want the light to come on. They don’t care about how it comes on. It just want it to work. And so I think over the years we’ve seen an evolution of the, the techie docs that either had to learn and the ball to learn operations and also strategy, right? Not just bells and whistles. Or they have done a devolve back to where they were really good individual contributors on the back end that they helped the teams. They do things like build technical tools. It helps translate which is needed, right? But you also need the visionary. You also need the CMIO type or the executive or the CEO’s executive doctor that understands strategy. These are our company’s goals, mission and vision for this year and a now backing back into what is the technology that can help us get there versus vice versa.

Dr. Levin: I agree completely and I agree. We need both types and that they’re increasingly distinctive there. There are the folks that like to be down in the engine room and our our tourists look at it, and then there are the folks that are spending more and more time up on the bridge. You said something else in there that I think is really important and I also believe has been a strength in your work. Essentially what I heard you say was start with the strategy. What are you trying to accomplish as an organization and then back and then back into how IT can enable that. Can you enlarge on that a little bit?

Dr. Butler: Oh my goodness. Yes, I can. And this was my Aha moment to be quite honest. It. Let’s say I always use a small example, uh, my wife and I will say, well, let’s go to Italy next year. Great. Okay. Italy being in Italy, walking those streets of Milan, northern Italy is the strategy, right? That’s what we’re, our strategic vision is, well now we have to back up a year or six months and said, okay, what are the steps that we need to take? Okay. Ultimately could get there right by the ticket, price it out, you know, uh, pack, who’s going to watch the dog? Right? Things like that. So I find that a lot of times healthcare systems are made up of so much tactics and fires of the day. They don’t always have time to think strategically. And especially since these EHR is have come into play because the EHR little, I don’t think folks have realized it has really shifted the dynamics of a hospital system where they can no longer think in silos. You cannot have the doctors just meat alone because whatever those doctors touch, there’s downstream of credits. So those folks need to be in their room. And that’s a very different paradigm shifts than any we’ve ever seen. Healthcare and companies struggle sometimes to make that shift where you said your iron triangle, that iron triangle, the people, processes and technology, there’s also a triangle within their clinical operations and technology. Those groups need to be there at the table and that’s been a big challenge for healthcare organization to figure that out. And then there ends up being a lot of unintended consequences on the backend because certain folks who aren’t in the room on the front end or one system may have used an isolated clinical EHR type system and there was a lot of manual work and labor done in the back end to make sure the bills got out and pay and all that. And now when she go to an integrated system like the epics and the (Inaudible) that does the clinical and revenue cycle, that’s a very different beast to manage to be quite honest saying, I don’t know, what do you think about that? But that’s what I’ve been seeing and realizing that the hospital systems are really challenged to pivot to a more collaborative meeting style. And then have really strictly facilitated meetings, strong agendas that work towards your strategic goals. I’ll say this one thing I would love to hear you say something. I love to hear your thoughts on this. I remember in 2004 I work on to (Inaudible) health system mark. Oh, second year out of residency. Lynn was the CEO of the, of the hospital system at that time he surgeon, Phd. Brilliant, brilliant mind. He came out to the western region where I started my little practice out there and it had a big a all hands meeting guys in your doctors and he said in front of that crowd and Oh four right? He said, if you’re ever in a meeting where the EHR epic does not come up in that meeting because this, at this time everyone was on epic at (Inaudible). Early adopters is that you may feel free to leave that meeting. I thought that was profound.

Dr. Levin: That’s fascinating. Well, I see a lot of the same things you see and this was one of the big surprises for me too as I saw these systems implemented. I mean I, I guess in a sort of intellectual way I understood that we were going to be moving more in lockstep, but I did not appreciate that we really, we’re now joined at the hip and as you said it, it’s not just the individuals but it’s the different departments and the different functions and so that I would argue that the implementation of these large scale EHR kind reveals the Cultural Dna of an organization. How good at you are planning and executing the project is one thing. How good at you are you at organizing two design strategy and operations and align all that with it. And I think that is the one of the central leadership challenges right now because as you said, we’re all, we all got to move in lock step now you simply, you can’t be a free agent the way you could in the pre EHR days. So increasingly what I see is organizations that didn’t have very strong organizational governance to begin with. Now having that stressed further because now they’ve layered this whole IT governance that sort of parallel but also overlaps with with the rest of it that, does that make sense?

Dr. Butler: No, no, no. You’re spot on it. It does. It does put more pressure on those organizations to organize themselves in a new way and they’ve ever had to include some of the ancillaries and those nurses where they didn’t quite have a voice. Just this morning, honestly, at tool Gawande released a new article in the New Yorker and I, one of the lines in it, he says the doctors, we’re used to having all the votes, but epic had arranged meetings to try that, adjudicate these differences. Now the staff had his safe parentheses and sometimes the doctors did demon show comma and they added questions that made their jobs easier. But the other jobs more time consuming. Basically he’s saying when you’re designing an EHR is because they integrate it. We have to be there together to do it together. If the physicians don’t show, typically the answer is the pharmacist. They designed the (Inaudible) cause they want to make sure that it’s done right for the physicians are upset now, right? The lab, they may design how the lab looked inside of epic because the doctors may not have shown up to that meeting. And so now they’re dealing with a lot of these things and they realize like (Inaudible) snap, this is integrated. I don’t like it because it takes what autonomy it takes, what it means a physician, uh, doing some of the things that I’m so used to doing. And also I feel at times, and you may know as well, it’s sometimes we’ll drive over with, does the HR or drive away in the doctor and the nurse relationship because of the formalities of the EHR. It’s uh, or between the nurse and the pharmacist. And so those are the things that we’ll have to overcome. Figure out how do we reinterpret, uh, the, the legal compliance and risk and privacy interpretation that we once had in the past based on a paper based system. Right. And those are the things that not all at this federal level, the state level. And now at the local hospital level, they’re all trying to figure out.

Dr. Levin: So true or false. And then I want to move on to our next question. True or false, you can walk into an organization, look at how they’re organizing plan and deploy their HR and based on the things you and I just talked about, predict with some accuracy how it’s all going to turn out.

Dr. Butler: Very accurate, very accurate. When you do this kind of work this long, you can pretty much, it’s almost like a uh, internist or a good diagnostic petition with, with human, the human body. Uh, there’s a couple of them, chief complaints you hear, then you look a couple of reviews, system questions you may ask, right? And then you may want to get a little bit of HPI but then definitely looks the past medical history or what is the history or the culture of that organization. And then you probably can make the diagnosis with a couple of times, right?

Dr. Levin: It’s so true. Good docs can walk in a room and tell where the patient’s really sick or not. I think good IT leaders can walk into an organization and tell very quickly, is this an organization that is doing it to its members or is it doing it with their members? Take it as far as you like. All right, so now I want to, I want to, I want to go on to question three and I to remind you this is a, this show is PG 13.

Dr. Butler: Uh, I can curse a little bit?

Dr. Levin: And Dave you’re a handsome guy, but don’t show us too much. Scan here. What’s your pet peeve or your favorite rants these days?

Dr. Butler: Oh Man. How much time you have on this one?

Dr. Levin: Well, minutes.

Dr. Butler: Great. Okay.  This is interesting. It sounds a little bit crazy and whenever it may actually limit the clients that may call me when I say this and that’s okay. But because it’s not a pet peeve, it’s actually something I think that we’ll get. We’ll get there in healthcare, we’re just not there yet. I feel that healthcare is really struggling to recruit talent from those, uh, dot com silicon valley, the startups. We really need to get these bright folks. And then finally when we get up, will land them, right. But what we ended up doing, and we asked him to do these Gargantuan (Inaudible) right? But what we do, uh, I don’t feel either we placed them in a position that may be five feet away from where they really you can excel, right? And of course she is a metaphor, right? But they’re almost where they should be, but they didn’t quite them in the right position to be successful or what we do, we give these really bright folks or these teams that we build within the, the, the, uh, healthcare systems to do really great work. I think we give them; we don’t get them the right tools, resources, and access to really effectively accomplish things that they need to do. Right. I always say it’s like, it’s like asking a Delta force or still teams are Army Rangers, right? To go on a mission and do some, you know, do all this cool stuff like surgical precision. Yet we have give them the exact same gear, equipment and resources that are standard military has. You know, and I just can’t tell you how many times I’ve seen it and great people, you know, I think it was uh, uh, Edward Deming that said, it says great people, uh, placed in a bad process. Uh, that is it. A bad system will be the good person every time. Right. And so I think that’s what I’m saying. And so those folks ended up getting burned out or they’re getting disenfranchised if they can’t work to the maximum of their knowledge. And so they end up maybe moving on and sometimes it’s out of healthcare. And that’s unfortunate. That’s one of my rants. I see a lot. I just really am amaze.d at how brilliant some of the, the folks that come through these organizations or

Dr. Levin: Well it’s interesting because I hear a couple of your themes in this one. I’m in. One is what can you reasonably expect from people? How do you prepare them? And I’ve always felt like, you know, it starts with I got to give you a reasonable tools. I mean, if it’s whatever the tech is or application, it’s got, you know,  (Inaudible), reasonable core functionality. The next thing is I have to design (Inaudible) workflows. I mean, it’s gotta be realistic that you can do what you’re being asked to do. Third is I have to try and support you.

Dr. Butler: Yes.

Dr. Levin: So that you’re adequately prepared to do the tasks. And then I think lastly is when we finally get to accountability, and that’s when we start to look at people or they’ve been given every opportunity and plausible workflow and are adequate support and they’re choosing not to do the right thing. We tend to be very focused on that last step. And we tend to shortchange and underinvest in the first steps.

Dr. Butler: spot on.

Dr. Levin: And then the other thing that you said, and I, I find this to be one of the most fascinating HR dilemmas in health it right now, is I agree with you. We need bright, fresh minds coming into health care, particularly into healthcare technology from a variety of fields. But health care really is different. I mean, I know it’s a trope to say that, but I think it’s legit. I mean, we’re highly regulated. What we could do very mundane, are exceedingly complex. They’ll cultures are complex, the reimbursement mechanisms are bizarre. The whole economic model is strange. And so I think the challenge is, you know, you got to preserve the important knowledge of the past and a dollar of practical things of what works. But that group also has to be wide open to brand new ideas and to people coming from outside and questioning what we’ve always done and say why you’re doing it that way. So I see most organizations are really struggling with this. How do they create this new blend of old and new of experience in healthcare and not so experienced in healthcare? Okay, Dave. So last question. What is your most sage advice?

Dr. Butler: Okay, this will be quick. I found my sage advice to folks that I run into a lot, a lot of positions or email me because they may be wanting to try something different outside of the normal traditional patient encounter type thing or a young folks, oh it’s coming up thinking about med school, residency informatics and they’ll call me. So I think the number one thing I tell them now is find a mentor. Look around, find anyone out there that’s doing what you think you might want to do and un-bill yourself enough to make a call. Call on three or four or five time bugged the heck out of them. Just say, Hey, I don’t want anything from you. I just want to know if we can maybe spend an hour every two months where I just update you on what I’m doing. And then you just tell me what you see and what you hear as far as what I’m saying. And, and helped me to get to be like, yeah, I don’t know to be like you even, you know. So these are things that I just had to learn and some of them, they weren’t always doctors. And also I had to learn like the mentor should be someone, then maybe I have a financial mentor, I have a spiritual mentor, you know, they don’t have to be the same person, you know? And so I think mentorship is so important and making time to get that mentorship is this invaluable, you know? And I think that’s my sage advice. And last thing is just always placed learnings before earnings, right? So many folks just want to, well, I can’t take a pay cut like that, or I can’t do this or I can’t do that. I hadn’t even heard students, even my own daughter, you know, sometimes their son, they may, they may frown upon doing things for free. A minimum amount of money, right? Building a website for someone you know, for, you know, just volunteering too. And you know, he’s computer science or whatever. I’m like, well, you playing Fortnight right now, uh, I’m about to build a website. Well, I’m just a good experience. You know? He’s like, oh, that makes sense. They don’t always think like that. Right. I think those are some things I really encouraged now with doctors, I say volunteer on a technology committee or something and that may cost you a little time in the evening, but I think you’ll realize over the long game it’s definitely, yeah, payback in 20s.

Dr. Levin: Well, Dave, this is why you’re such a terrific and well recognized leader in healthcare and health IT, I mean so much of what you said today are the basic elements of the servant leader. You surround yourself with smart people and you engage them and empower them. You ask a lot of questions, you think about governance and not what, not just what needs to be done, but how should it be done? You’re, you’re encouraging of people to use mentors and to focus on learning. Couldn’t agree more. I’m a, I’m a huge fan of mentors. I’m a huge fan of executive coaching. I’m a huge fan of formal cultural work in organizations. You’re singing all of my favorite tunes, that’s for sure. I’ll that I’ll never forget. I was contemplating a really terrific job offer. It was a big leap for me. And I went to one of my mentors and of course I’m a southern boy and he was a grizzled old southern gentleman, uh, who had advised me many times over the years. And he looked at me, said, well Dave, you did pretty good plan and the junior varsity is a chance for you to play for the varsity. And I knew at that moment, I knew at that moment what he was trying to tell me and what I should do. So I couldn’t agree more about mentors. Dave, thanks so much for talking with us today.

Dr. Butler: Yeah, no, this was great. I’m honored that you asked me to be on your show or your podcast. I know this is a new venture here. I’m excited. You know, once again, this is, this is what is needed, this kind of dialogue that happens outside of some of the normal areas of this healthcare informatics. So I’m all about it. Dave and I, I just think dance, they were doing some really cool things too. So, um, just going to plug you, you’re not just plugging me here. I mean, not even plugging. I didn’t like that word. I want to lift you up and continue your journey to save lives. That’s what you’re doing. Right, and I think sometimes that gets missed. We’re saving lives with this it stuff, as they call it. Right? And anytime we missed that, that’s the same on it. These are investments that we’re making and Haman lives. So thank you, Dave, for doing everything you do.

Dr. Levin: Thanks it was really generous of you, do like to think we’re, the work we’re doing is enabling a lot of good things to happen. Dave, you were terrific and I have a feeling we’re going to have you back.

Dr. Butler: Sure.

Dr. Levin: Yeah. You’ve been listening to 4x4 Health sponsored by Sansoro health integration at the speed of innovation. Check them out at www.sansarohealth.com. I hope you’ll join us next time for another 4x4 discussion with healthcare innovators. Until then, I’m your host doctor Dave Levin. Thanks for listening.