This transcription is provided by artificial intelligence. We believe in technology but understand that even the smartest robots can sometimes get speech recognition wrong.

[00:00:00] This episode is brought to you by CDW Healthcare. CDW understands how to connect the latest technology solutions and services to advance your healthcare mission while keeping patient and staff at the forefront. Whether you're looking to upgrade your EHR, redesign your infrastructure, improve care delivery at the bedside, or elevate the home health patient experience, Our dedicated team of industry tested experts leverage software, hardware, and comprehensive services to orchestrate cost effective solutions that leads to positive patient experiences, higher quality care, and more efficient clinical workflows.

For more information, check them out at ThisWeekHealth. com slash CDW.

the theory is if you could be offline for a week, truly offline, that means we literally turn off all the machines, all the computers, you probably can then get to the month. When you do those things, it becomes muscle memory.

My name is Bill Russell. I'm a former CIO for a 16 [00:01:00] hospital system and creator of This Week Health, where we are dedicated to transforming healthcare one connection at a time.

Now, let's jump right into the episode.

(Main) Hi, I'm Drex DeFord. I'm a long time recovering healthcare CIO. I'm now the Cybersecurity and Risk Leader at This Week Health, and I'll be the host for today's Solutions Showcase. First of all, thanks to you. We really appreciate you all attending and listening today.

I'll tell you, this promises, I think, to be a really good one. And thanks also to our sponsor today, CDW Healthcare. They have a really interesting story to tell and a very intriguing solution. This is something that I know a lot of health systems are worried about, and that's the challenge with business continuity and how organizations continue to operate.

When the computers go offline, and that is definitely one of those things that I hear a lot of CIOs and CISOs talk about. Our guests today are Eli and Rajeeb. Say hi, fellas.

Hi. Hello. Hi Rajeeb, Drex, and everybody else.

[00:02:00] It's good to see you. Thanks to both of you, of course for being here. The best way to start these usually is with some introductions.

Rajeeb, why don't you start by telling us a little bit about yourself and your background and the work that you're doing with CDW Healthcare.

Thanks, Drex. Yeah, my name is Rajeeb Ketuva. I'm a family medicine physician. Made the transition to healthcare IT about 15 years ago. Done a lot of implementation and optimization work with EHRs and over 30 health systems across the country.

I was a former regional chief medical information officer for Northwell, covered their central region, three acute care facilities and surrounding ambulatory centers. I was also the system CMIO of New York City Health and Hospitals, which is the largest public health system in the country. I led their EPIC install, was there about four years.

I was also part of the advisory board, which got purchased by Optum, and I led OptumCare's first EPIC install up in New York. I've been the Chief Operating Officer for ReMedi Health Solutions, and our company has [00:03:00] a big clinical background. We're physician owned and led. And partnership with CDW kind of makes sense in terms of our ability to provide clinical folks and some of these initiatives.

One of my favorite things about this, when I get to talk to folks like you and Eli, is that you're folks who have real operations experience in the field, like actually on the front line of healthcare your background as a physician, Eli's background as a CIO. These are always the best conversations.

I have a very similar background. So when misery loves company or whatever the right saying is it's good when you get folks together that have served on the front line. Thanks for being here today, Rajeeb. I appreciate it.

Yeah, thanks Drex.

And Eli we've known each other for several years.

I'm glad we finally have a chance to talk about some of the work you're doing and some of the things that you've got going on. Give me the quick two cents on CDW Healthcare and a little bit about your background.

Sure, thanks Drex. So I joined CDW Healthcare about five years ago.

Actually came via the [00:04:00] Sirius acquisition. Remember the company Sirius. before I joined Sirius and now CDW, much like yourself, a recovering CIO, I was a CIO for several different health systems in New York, both in public and in private, actually had the chance to first meet Rajeeb when I was one of the regional CIOs at New York City Health and Hospitals and then my most recent CIO job was at Brookdale Hospital before I joined CDW Healthcare.

Recovering CIO, longtime friend of yours, Drex never will say recovering friend. But it's just incredible that now within CDW, we get to really act as CIO for hundreds or even thousands of health systems across the country. So rather than being able to provide IT leadership, myself and my colleagues, we get to meet and help healthcare as far as technology across the country.

I think we're all very lucky to get to do what we do today. So you and I have been having a chat, all three of us actually were on the phone the other day, and that's the way this whole thing got started. We [00:05:00] spent a bit of time talking about business continuity.

And we've both been through natural disasters and cyber disasters. And we have this real world experience of trying to keep a healthcare system running when the technology goes offline. And you have a great analogy, and I think it's a great way to start this. Way, way back in the old days, like 2008, when 90 percent of the organizations in healthcare didn't have an electronic health record, they didn't have to worry about working offline because they were always offline.

But the story and Rajeeb, jump in where you'd like. analogy is one that kind of kicks off the whole conversation.

Sure. Thanks, Drex. Thanks. So the analogy that Drex is referring to is in the airline industry. And if you go back to, the Wright brothers and when airplanes were first created and everything was manual you depended heavily on the pilot and the cockpit.

And he or she knew everything from instrumentation and looking at paper logs and then fast forward well over a hundred [00:06:00] years now um, I would, I would argue that, the Nobody would fly from the United States to Europe without a human being in the cockpit, and nobody would fly from the United States to Europe without autopilot.

So as we've introduced technology to the cockpit, one of the things we never did was we never removed the human being from that. And the reason for that, frankly, is because there are components That can fail, and there's hundreds of lives on board. And if those components, those critical components fail, it can mean hundreds of lives at stake.

And the parallel to that is in healthcare, right? So everything was manual, charting, ordering medications in labs, imaging printing discharge instructions, and everything that was done, monitoring, was all done manually. And then, again, over, the decades, as Drex said, we introduced the digital concept, right?

Electronic health records ERPs RIS, lab systems printing et cetera, et cetera. And as we [00:07:00] introduced more, we saw greater and greater value. We grew more and more confident in the advancements of technology, right? It's really automation in a big way. So just

like in the airlines, they became more and more confident in the autopilot.

Right? Absolutely. Yeah,

absolutely. And I would say two things. One is. That if not for the introduction of malicious intent, meaning cyber attacks and things like that, we've had downtimes, right? It could be, someone, fat fingering a keystroke and bringing down a, server farm or it could be bringing down a network and we got better and better at redundancy.

We got better recovery. Historically for many years, We, the health IT leadership team, had a lot of control, right? We had our data centers, we had a backup data center, maybe a third data center. We had our own staff taking care of the network. Everything was in house.

And now we're seeing economies of scale and value of pushing a lot of that out. That could be hosted by the manufacturer, like an EHR being now hosted by them. It could be [00:08:00] things like software as a service. Going to, and think about your ERP and maybe that's provided as a subscription and a cloud.

And so number one is there's definitely malice and, unfortunate attempts at healthcare, we see that on an ongoing basis, but also we've given away the controls of keeping things available. And so I think we all agree. It's not a, if there'll be an impact, doesn't matter how much money you have.

how great your team is, things outside of your control will bring all or part of your technology down at a certain point in time.

2024 certainly proved that, right?

Absolutely. And so going back to the analogy of the cockpit, what we're trying to do is bring the pilot back in, not to fly the plane from takeoff to landing, but to make sure that the pilot is there.

Again, going back to the airline industry, they train every three months, every six months. on every single airplane type that they have the license to fly. So it's automatic, right? If there's a failure and they know how to what to do, they know how to safely land that plane.

They put them in

simulators, they run them [00:09:00] through terrible storms and all kinds of system failures to make sure that pilot can still fly that airplane perfectly. When things are going south.

And it could be, the instruments return, or it could be they have to safely land that plane at, some secondary destination.

look, I love a good analogy. And for me I look at this, the world that we're in today, everything's connected. As you said, we've pushed more and more stuff out of our own data centers and into the cloud or into software as a service. And so there's lots of, as I said, in 2024, there's lots of great examples or bad examples about how all of that can affect us and the delivery of care to patients and families.

Okay, that's the problem. We have automated a bunch of stuff. I love the analogy because my brain works in analogies. So this idea of we've automated a ton of stuff. It's actually become better and safer and easier for patients and families because we've done that. But we're not great necessarily at taking over control of the airplane when things don't work exactly right.

So that's the [00:10:00] problem. How is CDW and their partners approaching the solution? When we. Chatted several days ago. You switched up the analogy again. I love a good analogy. You switched up the analogy to baseball and you talked about four bases as a solution that you all have created.

Can you walk me back through that again with Rajeeb?

Sure. And let's start with the end in mind. So the end in mind going back to the, to aviation is that no matter what happens, it should be muscle memory. And, you think about those nurses that are on the floor that were there before the HR probably could get back into it pretty quickly.

And if there was no EHR or other system, some of the younger tenured physicians, nurses probably would not know exactly what to do or where that binder is or that downtime PC. So we try the home run is have it, we refer to it as like Semper Paratus from. Taking that from the Coast Guard, always ready.

We'll start from first base. first base is what we do, which is an assessment and it comes up with recommendations partnering with companies like [00:11:00] ReMedi with Rajeeb, and the reason why we partner with these companies, is that clinicians talk to clinicians. If you've been through an implementation and you understand it's a nurse that can relate better to a nurse Drex, yourself and I, we probably could fake it to an extent, having lived in health systems for decades.

At the day, I'm probably not going to know how much to titrate, a medication inpatient. But, so we partner with organizations like ReMedi and Rajeeb and his colleagues, and we provide clinicians of all sorts. Doctors, it could be a nurse, it could be a pharmacist, it could be a respiratory therapist whatever is required based on the specific needs of the customer.

First base, as we come on site, a lot of pre work is done, we really get an appreciation for their clinical, they're tier ones, right? They're critical clinical applications, business applications, not just clinical. If you ask a CFO what the most important application is, it's not the HR, it's probably payroll or scheduling, right?

So it's business and clinical critical applications, as well as all the underlying, underpinning [00:12:00] infrastructure, right? What are all the technologies that are required to keep that up? It could be the network, it could be, tap and go. It could be all sorts of underpinning. It could be how you authenticate using an Active Directory environment, etc.

So it's the Tier 1 and the Tier 0 and understanding what that is that they depend on every day to provide care. And then based on those assessments, looking for the weak links, we provide recommendations.

that requires some picking, right? A lot of times when you have these conversations with folks in individual departments or even on the IT team, those tier zero and tier one applications are not necessarily readily apparent.

Do you find that as you dig in?

100%. And we find often that, the IT team can provide us with that initial list. And that might be things that they're aware of. When you go up, walk out on the floor, you might find out, hey, this research person pays with their own credit card and they have this important online application that they use.

That depends on internet, right? That's an underpinning technology, look, doing drug [00:13:00] formulary look ups and things that were never maybe in the data center that you may not know about. We also find things that are required, like maybe, we were, Rajeeb and I and Timurana.

Customer side a few weeks ago and in one of the units, they had one downtime machine. Now, again, when we go as deep as saying there are no downtime machines available, our kind of worst case scenario, when we look and we do these assessments is you have power and you have oxygen, that's it. You don't have downtime PCs, you don't have printers, you have power.

So you have minimal lighting, right? Safe lighting. And you have oxygen, the nurses are not manually bagging patients waiting for the, restoration. So it could be. Generator provided power could be the main utility is fine, but that's the worst case scenario that we begin with and we say, okay, nothing else works, zero, not your central monitoring, not your ability to print out wristbands at the admitting, not your ability to look for, drug to food country indicators, not having, an EHR, not even not having the [00:14:00] ability to order labs, because, your EHR is down, or not even having the ability to store the image of a baby's footprint if the EHR is down after you take that when the baby's a couple minutes old. And we can go as far as literally, how can a hospital, the assessment and the recommendation to, to I'll use the word stay afloat for a certain amount of time.

And then, so we work off that. And just before I take a deep breath here the DMAR, the the goalposts can vary based on customer. Some will say, okay, give us a recommendation to be able to stay up for two weeks. The joint commission came out with a Sentinel event alert last August, which really lit up a lot of our customers, which basically said, hospitals need to be able to provide critical care without any technology.

We just always think about EHRs, but it's any technology for four weeks. And so that's usually the goal post that we start off with. That's first base.

First

base.

Second base is remediation. Okay. So now we know maybe our weakest link the organization is two days. [00:15:00] That might be pharmacy.

Think about fragmented downtime, right? If the whole system is down, it's Probably safer than if only pharmacy is down, because maybe their computers are hacked.

That can be the worst scenario when half stuff is up or half the organization is up and the other half isn't.

Yeah.

And you're CPOE ordering your medications, it's going nowhere. That's a really sticky situation to be in. So number two is remediation. Organizations can include us, do it on their own. That's second base. And they got to remediate it to get to their goalposts.

I'll ask Rajeeb to share a lot of how we look at the financial positions of this and how do we decide on what's a financially sensible recommendation versus what it might not be. Third base is then like a soft tabletop. So again, they can include us, they can do it on their own.

Take the emergency department. You'll have maybe everybody operate online using all the electronics available, all the technology, but have one or two clinicians work completely for a week on downtime. And they might say, okay, after two days, you know what? I can't. We [00:16:00] didn't think this through enough.

Let's go back to second base and remediation. Let's go back then again to third base and do a soft tabletop and see how far we can get. We provide a scribe, we'll provide, mentors and chaperones to help and to see if we can go through a week and then the dessert is the home run.

And what we recommend is, and we come with this in mind when we're doing our first base, assessment and recommendations is actually go through the health system a week at a time, taking a unit offline every single year, and that's what we call the Semper Paratus, the always ready. So just as an example, January 1st, that first week.

Maybe lab is offline for a week. Okay, again, a scribe and a mentor in the room documenting. If you can't go more than three days, go back. We work our way back again to the home run. Second week could be the ED, maybe followed by the OR, pharmacy. One of the off site clinics, finance, HR, payroll, labor and delivery, you name it, and we work that cycle throughout the year.

And the theory is if you could be offline for a week, [00:17:00] truly offline, that means we literally turn off all the machines, all the computers, you probably can then get to the month. And so that's what, our program includes. And again, going back to that simulator you mentioned, Drex, the airline simulator, When you do those things, it becomes muscle memory.

And when a hospital goes through that and they're actually down for a full week scheduled, then when it does happen, it's instinct. It's been within the last year where they've operated for that full week. And we look for things like supplies do you have enough prescription paper to do manual prescriptions?

Cause you can't do CPOE, right? Or do you have enough wristbands to write on? Cause now you're not going to use the computerized wristbands. All those things we look at. Supplies, training, every component of that. I promise I'll go on mute now and let Rich get a word in anyway. No,

I think it's amazing, right?

That just the idea of Sitting down and having a plan that is coherent and progressive like that from first base to second base to third base, back to second base, then to third base again, and finally maybe you start trying to hit the home run in some places. Just being [00:18:00] able to think about it like that, I think for a lot of health systems is pretty huge.

So we haven't heard from you yet, Rajeeb. What part , do you and your team play in all of this?

So we, as part of the first base, second base, third base, home run analogy, obviously don't want to go swinging for the fences because there's a lot of unknowns. So we do come in and do that assessment to get an understanding and.

What does that assessment consist of? It's an understanding of what their current state is with downtime procedures, because where we're, our focus is looking at the clinicians and what their ability is to be able to kind of function without the technology. And to be able to do that, you need pretty strong downtime policies, procedures, forms.

Eli did touch upon we do look at the details like, how much stock do you have of your downtime forms? Is it, will it last you 30 days? Will it last you two days? We got to find that out. But also, getting from the operational folks and the clinicians, what they feel are essential [00:19:00] functions.

And, doing those deeper dives to be able to continue functioning to safely take care of their patients. in OB, let's say, emergency C section, that's an essential function. Do you have the workflows in place on paper to be able to continue that? So those are some of the things that we look at.

But also, we also take a deeper dive and get an understanding of are the operational costs? Obviously, when you're going on paper, you're not as efficient as you used to be. You need more staff. You need and then, there'll be situations where you can't see the patient, as many patients as you were before, or, like the stamine increase, you may need, two or three more nurses per shift.

Runners.

Exactly, runners because that electronic communication of that prescription is not going anywhere, so you need a person to actually hand it over, hand deliver that. There's so many other in the OR do you make a decision hey let's not do those elective procedures right now.

But then it's getting an understanding of what is that going to cost you over that one month period. Working with [00:20:00] not just the clinicians, but then working with the finance teams and getting an understanding of, hey, how much is a traveling nurse going to cost to be able to supplement the staffing during this downtime period?

What is that, an extra half day, length of stay, what is that going to cost you? If we cut down all our elective procedures, what is that going to cost our health system? Getting them also prepared financially and operationally are important steps to plan for if the quote unquote some kind of disaster happens.

It really helps them understand the downtime what it really costs. And I don't think a lot of health systems necessarily have that number at their fingertips.

of the customers we're working with, the CEO basically said, if we're down for a month, we lose a billion dollars in revenue.

And obviously you can think about the credibility loss, right? Even if the recovery. And the goalposts there was. We can't lose a billion, we can't lose our credibility, and we need to operate for a month. And just to, one more point of thought about that [00:21:00] is, we talk often about going on deferral, right?

If a emergency department can't operate so they go on diversion. And sometimes that's not a possibility. Firstly, is you might be the only level one trauma in the area. So going on diversion is not. A choice, right? You don't get to make those decisions unilaterally. You have to do the best you can, but what we're seeing, and this goes back to, looking at the bigger problems that we're creating with good intent, is COVID, when a hospital had a problem, whether it was they didn't have enough PPE or staff, it wasn't a hospital problem.

It was a city or state problem because multiple hospitals are dealing with the same issue. Think about multiple hospitals in the same region that are all in the same EHR and all hosted, and it's a very scary thought.

Because if that EHR provider is down, and let's all agree that anything can happen, and we've seen that most things will happen, then there's no EHR in that entire area. And I don't want to say names, but I know that this exists because we talk to those customers, [00:22:00] and they say, you have to realize, we are all, not just the same health system, but all the health systems in that city are on the same EHR, all being hosted by the same EHR manufacturer.

So the region

could be down and there really could be no diversion option, right?

Or no OR no labor delivery unit, or no inpatient pharmacies, things along those lines. So we think about when we have those discussions, we also understand downtime options and we get into that level of depth to understand, okay, if you do need to go to downtime, I, as you mentioned, Looking at compromise, maybe it's half the amount of surgeries that you're doing, or maybe you close two clinics and you keep two open and you move the staff over for efficiency, etc.

We look at the business impact to the organization, but also the abilities for the other organizations around. It's really power and oxygen, and how do we stay afloat safely?

Rajeeb, I feel like we may have jumped in on you there. Are there some other things you wanted to tell us about?

I think I got across the major kind of assessment piece, but, It's [00:23:00] also it's interesting though, when we start talking to the clinicians, they're not thinking about downtime. One of the things we do find is people that are on the day shift, they have no idea.

But if you're on third shift, you're, you have a good idea of what downtime is, because when we have these upgrades and things, they go through that trial run. So I think that really cements the methodology of getting that simulation or kind of. What just the real kind of experience of

going through the downtime process helps them get to where they need to be. One of the things that we do find is that the there's no real kind of education or training on what to do during a downtime. lot of times we see a lot of health systems don't really have a good process of How to communicate that we're on downtime.

So we're actually looking at a lot of the very basics of how do we prepare for this? They're all comfortable with a prepared downtime. We can prep for it, we can get ready, but if it's out of the blue and you're not prepared, it freaks them out.

And then you start off with that, [00:24:00] like, how long do you think you can go? And most of them say, maybe. Two hours, two days, but nobody says, but when you say like, how about a month? They're like, Oh, can't do that. But can they can, it's possible. It's just just getting prepared for that situation.

You just gotta, and I think Eli kind of mentioned, it's not a question if, but a question of when. I think we just have to get all the health systems prepared for that. When it happens that everybody's on the same page and can continue to function.

It's interesting to as you think about this, I'm not even sure, this is why starting at FIRSTBASE is really important because there are a lot of folks on day shift who've never experienced downtimes other than just the oh no moment that happens when for some reason the systems actually accidentally go offline.

For one reason or another and even then, and what the other thing is, I have realized as I talked to nurses who are on the overnight shift, who are the ones who, to me, always used to be the folks who were the most prepared for downtimes, because, as you said, that's when we took our upgrade time [00:25:00] and all of that.

But even now, it feels like they are so confident that the system is going to come back on time when IT said, we're going to take it off for, two hours and we'll be back up at three o'clock in the morning. They're so confident that even they don't necessarily go to downtime procedures now, they just hold their breath for two hours and then go back and do all the entries.

So we've really lost a lot of the bubble on business continuity when we're down.

Yeah, and I think, some of the EHRs go, they're going through these quarterly upgrades without, there's barely any downtime now. So it's becoming more and more of a distant memory.

They've gotten really good at it. They've gotten really good at it. Okay. Fellas, I'm almost out of time for the folks who are listening and are intrigued about How to go to first base, second base, third base, maybe hit a home run. Those resiliency needs at their organization. Eli, what's next?

Who do they contact? How do they get started? What do they ask for at CDW?

I was going to talk about it, give you a call this afternoon, [00:26:00] Drex. But seriously though you can definitely reach out to me, eli. tarlo at cdw. com. You can reach out to your CDW. Sales professional, many people know about our healthcare strategist team.

You can reach out to any of the healthcare strategists definitely can reach out to me directly or any of your direct contacts at CW and we'll bring you in to this program. And ultimately you'll walk away after this journey of being able to rest assure that regardless of what happens, you're You'll be able to provide safe clinical care with minimal financial impact

Thanks. I really appreciate you guys being here today. This is a really hard problem, and I know it's a really hard problem that a lot of folks who listen to the Solutions Showcases, listen to a lot of the stuff we do at here at This Week Health. It's a problem that a lot of organizations have, and the kind of thing that I know when I talked to a lot of CISOs, they say, I may not be responsible specifically for business continuity, but it is a thing that eats at me every day [00:27:00] because I know that we're challenged there.

So I really appreciate the work that you're doing. Eli, Rajeeb, I hope you'll come back soon. Tell us how you're progressing with some of the customers who've leaned in on this really great idea. Thanks for being here today.

Thank you, Drex.

Thanks for listening . If you found value, share it with a peer. It's a great chance to discuss and in some cases start a mentoring relationship. One way you can support the show is to subscribe and leave us a rating. it if you could do that. Thanks for listening. That's all for now..