Designing for Health: Interview with David K Butler, MD [Podcast]

A health system’s medical record transition, whether from ‘paper to pixels’ or to a new digital solution, can sometimes be a challenging journey. Technology or software can be well-designed, yet still not meet the needs of a every user. One of the keys to a successful implementation is ensuring that customized workflows and designs exist for the wide variety of clinicians that interact with it daily. While allowing customization is vital to ensure buy-in from key stakeholders, giving too much design control can often lead to an environment of overwhelmed and confused clinical staff. Finding the sweet spot between customization and control is paramount for successful implementations and future digital transformation

On today’s episode of In Network's Designing for Health podcast feature, Nordic Chief Medical Officer Craig Joseph, MD, chats with David K Butler, MD, interim CMIO at KeyCare and founder of Calyx Partners. They discuss the history of early electronic health record (EHR) implementations, Dr. Butler’s journey from physician to clinical informaticist, and how to win over skeptical clinicians during implementations. They also talk about taking inspiration from other industries for future transformation, striking the balance between customization and control, and building trust within digital solutions.

Listen here:


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Want to hear more from Dr. Joseph? Order a copy of his book, Designing for Health.

Show Notes:

[00:00] Intros

[02:11] Dr. Butler’s background

[03:42] Internal medicine vs pediatrics

[05:36] Going from paper to pixels

[10:20] Dr. Butler’s “aha” moment

[15:38] Gamification of the EHR

[19:20] Balancing standardization and customization

[31:05] What it means to be a virtualist

[36:50] Handling change within the EHR

[39:55] Dr. Butler’s favorite well-designed things


Dr. Craig Joseph: Welcome, David Butler, to the show. How are you today, sir?

Dr. David Butler: Doing well. Doing well. Thanks for having me, Craig. Yeah, I'm looking forward to it.

Dr. Craig Joseph: It's a pleasure to have you. We have known each other for how long?

Dr. David Butler: Aw man! Oof! Well, what, 15 to 20 years?

Dr. Craig Joseph: It's been almost 20 years. I just did the calculation in my head. It's been almost 20 years. I think it was 2005. So maybe nineteen years. And in that time, you have been involved very significantly in the healthcare IT world from all different sides. Where do we find you today? What are you working on today?

Dr. David Butler: Yeah. So a couple of things going on with me. I'm the interim CMIO at a virtual company called KeyCare. Lyle Berkowitz, CEO. They're also the first Epic virtual platform ever in the U.S. So that has a lot of implications for connectivity. They talk about that, so it's pretty cool, I’m doing some also CMIO-type coaching, mentoring, advising on some startups, third parties, things like that. Really cool stuff, just a diverse group of things right now. So it's kind of cool learning new stuff, especially the VC space I just don't know that world at all. So a lot of cool stuff there.

Dr. Craig Joseph: Awesome. Well, why don't you give us a little background about how you got to where you are? You are a physician, I know that. Talk to me about what your specialty is and how you got into this, how you got into this field. How did you get to the current Dr. Butler we all know and love?

Dr. David Butler: Well, first of all, I'm a Texan by the voice, you’ll probably pick that up sooner or later. The y’all will start coming out. Born and raised, Texas. Small town. When you think of Friday Night Lights, whatever you think of, that was my life. Went to Texas A&M undergrad. Then from there, med school in Houston, UT med school. And that's called McGovern.

Dr. David Butler: From there, across the street to Baylor College of Medicine, trained in internal medicine and pediatrics. Yes. Did both of those. So they took six years and crunched it down to four and made me take both board exams, pediatrics and internal medicine exam. So had I known that that last statement probably would have changed a little bit, I was really excited. I learned everything 0 to 99, which is really cool. I loved learning and Baylor was awesome just to learn in the medical center of Houston right during that time. Also, I had a daughter and well, this is like, well, I had my kid one month before med school when we got married the weekend before med school. You do the math on that. So it was a little bit trickier, but through all that, finished up residency, moved to the middle of Pennsylvania with the kids and wife to a company called Geisinger Health Systems. And that's where I ran to a little clunky piece of software that was really slowing me down called Epic.

Dr. Craig Joseph: That Epic. First of all, I think the question that a lot of our audience wants to know is, which is better, internal medicine or pediatrics and why is it pediatrics?

Dr. David Butler: You know, that's a good question, because people ask why did you go med p’s? Why didn't you do family practice or why did you do internal, one or the other? Right. And I had to think back, I was just talking to someone on the plane about it. I think she's a resident now, going to a practice, and we were talking and I, I think what it was that it was the residents that you work with as a third and fourth year that after a while you’re like man they were really cool. They're kind of they're like a vibe, you know, and certain things like, what do you do? I’m a Med Peds and I’m like, what is this Med Peds stuff, right? So it was more of that and I think it was a, I guess this ability to code switch, medical code switch like from pediatrics to adults like everything, like to go hard internal medicine especially at Baylor it was very like no jokes button up your white coat. You know one of those, right. And then pediatric side where you had to lose all that seriousness. So you're dealing with parents, kids and all that. You have to flip. So I think maybe that sort of what was attractive was the personality. But yeah good feel and I loved it and there at Geisinger where I first started practicing and get my chops as I was basically hospital based when I got to Geisinger, they were looking for somebody that could go between hospital and clinic and this was 2003. I'm like, I'd like to do that because I don't really care about outpatient as much as I care about inpatient, because I know inpatient very well. And so I did a combo role where I was hospitalist in the morning. Working at Mount Whitney medical center, a little local hospital there. They used Meditech, by the way, and I think that's part of my origin story. We'll get to and then you go back in the clinic in the afternoon. You’re seeing patients that were discharged a week ago from us in Meditech, but they're in our Epic system with no information. And that was around 2003-2007. So that’ll give you a little bit of insight on where we were in the world for the paper EHRs and all that.

Dr. Craig Joseph: So but when you were a resident, you were at the VA where they went from paper to EHR in front of you, did that happen?

Dr. David Butler: Yes. Yeah. And that was probably some of the more traumatic events of my digital technology life as a resident. And the Houston VA, which is the largest federal building outside of the World Trade Center in the U.S. The Houston VA is huge, right? We could literally run down a hall for a quarter mile. The hallway is crazy. And so long story short, they flipped the VA from, we used to do these VT 100 terminals where you write your note at the end of the day, you write your note in, typed in the computer, but then you do your orders on paper, you give it to the clerk, they fold it up, you know, send it to the pharmacist, the nurse, whatever. The clerk was like quarterback, right. An overnight, Craig, I joke with you not, you know the word, beep that. Can you beep that sound like I said but didn’t? Okay. Anyway, so yeah, overnight I felt like the electronic record came in and what used to take like literally 5 seconds to start a drip an IV drip or where there's nitroprusside or whatever. Those crazy stuff we used to do that would take literally 5 seconds and the patient would have it in their veins in a matter of like probably a minute. And all of a sudden that process took 20 clicks, and I still wasn't sure if it went anywhere. And that was my first aha moment. Like, okay, this thing could go off the rails. If not done the right way. And so, the VA was my starting where I first as a resident, you had to use it if you're trying to get home. Right? And so all these attendings, all the older docs would be just circling, waiting on us to finish our notes so they can copy and paste and get out of there. And that was the world. That was the world I got introduced to when it came to converting electronic health records to go from pixels to paper, as I call it, crazy.

Dr. Craig Joseph: It's funny, one of the things we talk about in human centered design is, transparency and visibility. And what you're describing is, is classic of going from a transparent system to one that was more opaque with the electronic health record, because as you said, when I wrote when you wrote in order, you took the order and you put it in the area where, you know, a clerk or nurse or someone was going to see it or you gave it to them directly.

Dr. David Butler: Absolutely.

Dr. Craig Joseph: And then you lost that ability because you pressed a button. And did it go anywhere? I'm not sure if someone’s going to see it. Did I do it right? There's no transparency there. And so you're kind of going against the laws of of design at that point.

Dr. David Butler: Yeah. Laws of design and more importantly, laws of human patient care which is what was freaking me out. Right. It's like, where did that go? Where is it? I think I ordered it. And that was when I realized, like, we really got to get good real quick, real fast in healthcare as we get into this digital space, especially patient safety was a driver of the HER. And this is where I feel as I reflect back, I wish we separated things out. I wish we had done documentation first. Let that go for everyone across the world. Right? And then we bring in ordering, right? Inpatient or outpatient, but not only medications. Right? The medications are the thing that hurt and kill people. Right? And so why do they make us all to x rays? Diets? my God. We have to order every darn thing. I'm like, wait, something just jumped the shark here. And I think that's when I realized that in residency and I was committed to say, okay, what I'm not going to do is give my career over to the technologists, okay? Because this wasn't a good vibe in the early 2000s with anybody in IT And I think any doc on the call will probably vouch for that statement because if we were in a new world and we felt like the hospitals IT could not meet us where we were as far as getting patients taken care of safely, effectively, efficiently and all the quadruple aim stuff today. And so, yeah, I think our generation outside generation, you know I’m 52 you're probably 90, I don't know. Craig. But our generation, our generation, think we were the paper to pixels generation. We saw that transition, right. And now we're in this. And so those folks that are behind us, have benefited from some of the, you know, they just their started their career CPOE, they have no paper concept, you know. So I think that's easier mentally, but it's still occluded and we've got to keep working through those. And that's kind of what led me to what I do today is workflows. I had to ask myself, who created this button? Find the person who made this button because this thing is not working right. And they always say, is it working, is it working as designed? Working as designed. And, you know, I was like, but is it working as I would expect it? So how about that? Can we ask that question? Is it working as expected? Because I don't care how it’s designed, right? I do care how it’s designed, but it has to be designed and working as expected. Is that a safe statement?

Dr. Craig Joseph: I think it's safe. So how did you go from just someone, a physician, using this technology to someone trying to change it or at least understand it better?

Dr. David Butler: I think, you know, I think my aha moment came also the second revelation from one pain in residency to when I got to finally working at Geisinger using Epic, the software at the time and at Mount Whitney’s medical center, they had Meditech, and both systems were very difficult to navigate effectively. And it wasn't until my in-laws bought my son an Xbox and he was too young for Xbox. So I took the Xbox and replaced all the Wii, right. Or whatever that was he needed back then. Right. And it was when I opened up Xbox, I put in a DVD called Halo came with it. I never heard of Halo, never heard of Xbox at the time because I hadn't gamed since college. Man, I put this in me and I remember the night I was in a basement. I put it in and had a big screen TV because I was what I treated myself from. You know, one time you're not a resident. So opportunity. We all did that. And then when I put it on his big screen TV in the basement, that was a visual experience, man. I hadn't seen before in a video game. It was first person shooter. So it means that you're seeing the world from your view, right? And you land on a planet and you're this guy named Master Chief and you're on that. You're the persona. And as you're walking through this world, the non-player or whatever they call those characters or took all those characters that you know, that interact with you but not part of the game. Non-Player NPCs, maybe Non-Player character, Non-Player character.

Dr. Craig Joseph: Yeah. There you go.

Dr. David Butler: Yeah. Yeah, right. It's something the game is this cool? Right? Anyway, so these, these non-player characters were interacting with me, but to help me now figure out how to use the joystick like, Master Chief, I'm like, Hey, try squatting down. Okay, how do you squat down? And next thing on the on screen it'll give you how to do it. And that's when I realized. my goodness, we're outgunned. If this video game in my basement by myself is teaching me how to use this complex controller while navigating the three-dimensional world that has these beautiful stars, mountains, landscape water. You walk into water, you can hear it, right? You're the plasma rifle you're carrying has a shadow on the ground. And there's no sun in this world, Right? It's like, wait, what is this? And then I realized that game is made up of all ones and zeros. A human did it and an EHR is made of 1s to 0s and humans did that. Well, what's the next logical thought on that one Craig is like somebody is not talking right? I mean, I can literally take lives, virtual lives of people all night in this video game or aliens easily. And it takes me 40 clicks plus 15 mouse miles. I don't know, to order an IV drip the next day in the hospital. That's crazy talk.

Dr. Craig Joseph: So why do you think there was and probably still is, a big disconnect between what you had at home in your basement and the technology that you were using in the hospital.

Dr. David Butler: And you probably help me out with this one as well. My thoughts are that I looked at a little bit. I think there's the financial models right now. The gaming industry almost fits in entertainment. Right. And I think we have misaligned and misprioritized things a bit. And you know, when you're designing for a single person or persona, you're going to be very mission focused, Unlike the electronic health records, which it's like a big Swiss Army knife that everyone uses a little bit differently.

Dr. David Butler: And so I think from a company vendor shipping out a product and not allowing, if a user adjusted it personal settings on those video games it’s just for me. But when you start touching a setting like Epic, well, you're not only affecting you, you may affect that group of you. And so those are decisions that need to be made now, right? So now you get into governance. Like what changes do we move this? In Halo, I mean, when they're testing Halo before they ship that they have like 20 all aged people lined up and they had girls, boys, they had grown men, women, and they had all sorts of folks lined up and they put these phobia cameras on all their eyes and they tracked everywhere. They're going around these fantastical worlds. Right? And at the end of it all, what they knew was like they were gaming. They were going for about 13 or 16 hours of gameplay, I think, because at that time they knew if you get 13 or 16 hours a gameplay that's your sweet spot. The game works, right? And so if you go below that, it's too easy. They get bored of it above it’s too hard, they'll abandon it, right? And so they continue these tweaks where they would look for, see where the hot spots on valleys and riverbeds, wherever the aliens were pretty aggressive, they'd see all these hot spots where the players weren't succeeding. Right. And they looked at it. Now, ah, we didn't make the weapons or all the things that we planted in the bushes. They wouldn't make them big enough so the players could see it. So when they increase the size of it or they gave them extra weapons in that area, now they saw that they got out of that area. Right. It was just the study of just a video game Craig, I mean, we’re saving lives, this is a video game. All this work went into the video game and we and at the time, I couldn't get my company to even pay for a couple of a piece of software called Camtasia that I could use to make a training video for docs. And so I think that was a disconnect, you know.

Dr. Craig Joseph: Well, let's talk about the video game for just another second. So gamification, you know, the idea of taking something that's work or, you know, not that much fun that you don't do on your spare time and turn it into a game. Can we gamify the EHR a little bit more or is that are we doing that at our own risk?

Dr. David Butler: I like that concept. I think that there are some things that we can continue to steal from every vertical, not just the gaming industry. Definitely gamified. Gamification worked. We know psychologically you got to figure out what is a what is a dopamine hit? Where can we find some dopamine hits, right? In the EHR. But in order to know that we have to interview, we have to understand the users, right? What do they care about? You know, and also sometimes you can't ask them questions sometimes about this, don't know. And also, muscle memory is so strong in there where you say, so how do you order say, Augmentin today? How many clicks does it takes to order Augmentin before docs complain about. Well, I can't find the echo anytime I ordered it, so I just have my nurse do it, you know, whatever. Whenever you do that, what we find is that physicians as a whole, typically when we get frustrated, we get quiet. We don't I mean, we may complain once or twice, but if we get no response once or twice, that's done, you know? And so the silence has been mistaken for a good thing, because when you know, you and me, we go in the companies, we evaluate them as a consultant, as a strategist, when you're talking to folks sometimes, well, the docs don't really complain about that. Okay? I don't complain about Outlook or …

Dr. Craig Joseph: Well I do. Just for the record, I do complain about Outlook, but yeah, go on.

Dr. David Butler: Exactly right. Yeah. But you know, I think those are not like silence is not golden. Unlike in the movies. Right. Sorry. Silence. I mean, you'd better take a peek at that. And so what we've been doing lately, though, was leveraging data to help get the volume of the docs, right. I mean, you can ask folks things just like medicine, right? And I approached the consulting with companies like you are the subject. You're the voice of the customer. What are the docs what are the complaints. Right. Get that subjective right And then you say, okay, objectively, well, what's the data like? Do you have any data or objective data from Epic, the software are they using it or things like that. Look at the data. Right? And you can even augment that with a nice survey. So filling those gaps between what the docs say in the survey, right. I mean, what the data says and then after that you come up with it, you know, almost like an exam because it was sort what's going around. Look at the place you know, people process in tech and then after that you come over to a nice assessment and here's a plan. So that's kind of the way I approach this type of things. And what I focus on most, what we should focus on most now, I feel, is UX and UI. That's just a big word for a user experience and user interface. A lot of docs and people that use these tools don't realize you can easily move that button here or move this here or remove the clutter. You know, I call it Marie Kondo, you can Marie Kondo the hell out of this thing. If you want to take a minute to do it, you know, to really make your workspace minimalist and so your attention goes where it needs to go at any moment of the day, and that your most common task or the things that you do daily the most is streamline, automated or whatever. So that was a long-winded answer to your question

Dr. Craig Joseph: So that brings up an interesting point. How much control do we give to the user and how much control do we keep on the on the administrative side? If I let you change all kinds of things and it's going to be very difficult to support, right? When you call the Help desk, I don't know what where that button is because you changed it and the person next to you can't necessarily help you anymore if you're like, wait, where's that thing? it's the button on the left wait I don't have a button on the left because I changed it two years ago and I don't remember how to do that. So where do you actually where is that sweet spot of kind of standardizing on one hand, but also allowing the individual user to to change the things to make it work specifically for them.

Dr. David Butler: Yeah. Well, that's a solid, and I don't think I'm going to give you a good answer for it. But there's a couple of examples I think that folks will resonate with, like, we need to think through. And, and just sometimes when I have a hiccup or when I really just jacked it up back in the day giving the docs way too much control and causing confusion and everything you just said versus being more paternalistic and taking everything away, right? It's like there's somewhere in the middle and I find that it's usually organization types of, for example, Bon Secours. We were 15 hospitals, five states. Right. Okay. And within a hospital, there's a lot of variation. Okay. Now within the next hospital, two miles away, there's a lot of variation. Okay. Now, in the next state in this hospital, there's a lot of variation. So the question is, does that the tools that we provide for the nurses at a hospital A work for B, right, in the same region? And then let's extrapolate out to a new state like New York, right? Well, the nurses have very limited scope of work because they can only do like 2 hours. I don't know if this is true, but it's still felt that way when I was, okay. Please check the ranks, New York, check yourself. And California. You too. Anyway, it's very limited. Okay. And I like what is going on, but we had to understand that. So we can now create the software effectively so that the nurses work within a scope of practice. Whereas in Texas or some of the other places I've consulted, Guthrie, the nurses have a little bit more range. They can do more. So you could give them more permissions in the EHR. This is a really interesting topic. These are niche areas that your viewers may or may not know about, but everything we do in that EHR has like a switch that should they be able to do this or that, Yes or no? Yes or no? Almost as Outlook. Like, should we allow every user to reply all or not? That's a really big decision, right? And how would we know that? So that's the things that we've been dealing with over 20 years with this EHR, who should be able to do what, when. And so managing all the complexities of that with of the technical complexity, with real life, where we all know this, the EHR is made up of one two zeros, the human body, oof. I mean, that's like at least 206 shades of gray, right? I mean, this is not black and white at all. And so what we've done is try to get these very rigid IT systems, ones and zeros to accommodate a very complicated model of human care, caring for humans that we didn't., and we still are practicing that with the practice of medicine. And so I think that's really what we’re into. And now you've got to mix the complexities of healthcare in the U.S. And I’m gonna say that again, healthcare in the U.S. is very complicated because of the payers insurance want certain things from the EHR, the doctor's workflows. But now we have to think about that when designing when we never had to think about that with paper and a pen. Right. Paper and pen, you walk in the room, you give them what you give them. There you go. And all the magic happen in the background and all that background that has been pushed to the front. And that's what we're seeing across the U.S. Physician burnout, you know, due to administrative tasks being pushed to them that and also folks not working to the highest of the licensure. I mean, I can't tell you how many times I've been an organization where they have an RN. We did some data reports we had an RN that was consistently taking vitals in the clinic and they had like at least two images in that clinic. Okay. That's all I'll say about that statement. Okay. An RN that is taking vital signs, but you have MAs there that could do that. And so the question is, is there higher levels of work with the RN could do based on the licensure? Right. And maybe is that a technical problem? No, it's not a technical problem. That's an operational problem. Right. And so I think what Epic and these softwares have done, it has forced hospitals to grow up mature, standardized things really fast and to sustain it. And I think hospital systems are now realizing, well, the software is kind of cool, but at the same time, it takes a lot of work.

Dr. Craig Joseph: How do you find that sweet spot between, I'll give you the stereotypical IT answer of no, everyone gets that. Every nurse has the exact same screen because nurses do the same things and every doctor is the exact same screen because they do the same things. That maybe is the far shifted to the IT version as possible. Now to the doctor and clinician and nurse version is, hey, I'm a cardiologist, but I practice differently than the cardiologist next to me. And so don't even tell me, I don't even know what a gastroenterologist does. That's a different planet, they’re aliens to me. And so I need to have exactly what I want, the way I want to see it out for every screen. And clearly both parties can't get what they want. So there's going to be somewhere in between. I think it started off 20 years ago as much more on the IT side, right, like hey and either A our software doesn't have the opportunity for you to personalize or B if it does, we're not going to give it to you because we think you're going to mess things up. And when you call us and ask us questions, we're not really going to know how to answer them because we can't see exactly all the changes that you've made. Right. And I think we've moved further to the right. What with giving users more opportunities to kind of standardize. And yet I'm still frustrated as, and maybe you are as well, still seeing physicians mostly, I'm going to pick on this physicians not other clinical folks, who complain for valid reason that there's too many clicks or this is really not intuitive. And then when we offer to kind of help them or, you know, hey, there's ways you can personalize these screens to make them look better, they say they don't have time.

Dr. David Butler: Yeah. So I call that, I call that, there's a phenomenon I think I'm going to label called the rental car phenomenon. Right? You ever go on a vacation, you get a nice rental, right? Like, you know, you got the Sirius XM radio, you got the CarPlay built in where your old 2016 Ford, mine doesn't quite have that. And so you get used to a different level of tech and experience. Right? And then when you come back you're like, your car is not like it used to be. Your TV's not is better than hotel TV, whatever. Right. Well, the same thing happens with docs, but it happens every day with their iPhone, with Amazon, with things that they use that are intuitive and then they come back to the EHR like ugh, right? They don't know they're feeling that, but that dopamine hit happens. Okay, because that's what we do. Like they're experiencing really good tech outside of healthcare daily, outside of their job, whether it's the iPhones, the cool apps, the chrome extensions and all the cool things we do, right? And to be efficient. But then within our practice, within healthcare, it's like, nope, we can't do that. No, we can't do that. So right now I feel like the patients have so much tech and they're, the docs are kind of, we're still playing defense and man, we're playing defense as best we can because our health systems are slow as heck to get us the right tech. AI, a great example is this AI stuff, right? This AI should be all over the healthcare system right now, and it's happening faster than we think. When I say AI, narrow, narrow AI, for example, the note decks, those things like that work that got mature really fast and that is probably going to be the number one savior, I'll say, of physicians’ time and brains in the next year. That's my prediction on that one. Because if we can get it rolled out to those guys fast, to the folks on the front lines, faster, right? And that means go and do legal, risk, compliance. I know all of them. And this helps us, all work for large health systems, not getting through those for legal risk compliance and quality. You know, those are some really hard barriers of getting things to the front line of the docs, so everyone almost has to sign off on it somehow, you know? And so I think once we get better at streamlining those processes, say, okay, this does this, this, and here's the negative effects of it. And if they're negative, how do we mitigate that as a system? Focus on that and then let's get it in. Amazon got one click God knows how long ago and I'm sure there were folks like, Well, you can't do that Amazon one click. I mean, come on what if, what if, all the what abouts, right? It happens in the room. Well sometimes you better make a decision, right? And then be ready to mitigate. Okay. And I think those are something when you make a decision with incomplete information, that means you'd better have a a game plan to say, if this happens, we got to do this. If this happens, we'll do this. And I find that healthcare, sometimes we don't make a decision until we have all the data in 100% accuracy shot, you know, and that's just unrealistic in 2024.

Dr. Craig Joseph: That's an excellent point. So from a healthcare system or from a hospital, administrative or from an IT leader standpoint, you're absolutely right. We can't, you know, paralysis by analysis is the term, right, that we just can't make a decision until we have all the information. However, every single day doctors and nurses and therapists are doing exactly that, right, in the emergency room. They never have all the information that they need and in the middle of a surgery, you don't have all the information that you'd like to have and you have to make a decision. And sometimes you go with your gut and oftentimes it's the experience. But we're not able to kind of leverage that on a system wide standpoint. I get it. But it's still, you know, it still stands that you're at some point going to need to make a decision and move forward. And no one knows exactly where that point is, where, when do I have enough information and experience to make a decision when I'm representing the entire system.

Dr. David Butler: Solid, solid. And, you know, I've been in those positions when I see email where, you know, like, well, if I approve this, this is going to be turned on is going to affect, you know, the doctors right now. That was a gift and a curse that we've been given as CMIOs. Right, now I take that, I remember when the times came, we had 36,000 diabetic patients read like seven tools that we were going to push in Epic. And they were going to help all docs manage diabetes better. Right? And I just remember like when that happened, that was like the next week it was almost like I was like, wow. You could see, like folks are using the tools that I came up with and you can almost see like, okay, hemoglobin. I went, these are going down over the next year. And they were directly linked to those tools. So that told me was, wow, just like you can make things bad things go viral, maybe you can make good things go, Wow. So that was my hook into this whole game and say, How can I do that? How can we do this for good? How can we make clickbait? That's cool clickbait that I'm saying, how do we do this for good? So that's kind of the way I like to approach things. Now I steal from other entities whether that's banking, restaurant, whatever ideas I see, those are how can I put it here and make it cool, you know? So I think that Segways well, I think I read in your book you said the world in your book, Greg, you said this and I forget the pages that we need more CEOs, we need more chief imitation officers. Yeah, I thought that was really cool. Yeah, I love that.

Dr. Craig Joseph: Let me be clear. I don't think that, that's certainly not my line. But the idea is that there's so much good out there. And why are, why does everyone think that they need to figure this stuff out on their own? Just find what others have done. And if it, if that works for you without modification, then just, you know, use it. That's, I mean, that's what that's, that's what we do in healthcare, right? That's why we published a study to say, Hey, I found this thing and, and hopefully it works the same way for you and your patients as it did for me and for mine. Dr. Butler, you mentioned earlier in the podcast that you work for a company called Key Care. You mentioned that the CEO and founder is Lyle Berkowitz. Long time listeners of the pod will perhaps remember Dr. Berkowitz was actually the first person we interviewed for the podcast. So it's all going in a circle now. Tell us a little bit about Key Care and can we, I'd love to focus a little bit on what you do with with virtualists. First of all, what is a virtualist? And secondly, how do we help these people?

Dr. David Butler: Yeah, so virtualist is a term, relatively new term to me, kind of like back when the word term hospitalist came out. And I think maybe when the word SNFist, remember SNFist, S capital S N F, that is a person that handles …

Dr. Craig Joseph: I think you're making up stuff now. Now you're just making up stuff.

Dr. David Butler: I may have made that one up, but you get it. Virtualists are providers that typically spend like over 80-90% of time in a virtual setting as far as care for patients, not necessarily in real life, brick and mortar type. Okay. So this Key Care platform is a start up maybe a year ago, been like a year ago and, I guess I get a call from Lyle maybe in the summer time. Says hey Dave, you know. You got a minute? Say yeah. What's going on? Say yeah, just got some, you know, some white noise we're hearing from some of the users of the software. They want to take a peek at it and maybe also serve as interim CMO for a while. I'm like, great, let's do it. And so while in there, just like I said before, how we are, you go into a system, you look at things, you say, who was talking, you like, can we get can I interview docs and things like this? Well, virtualists are so busy, right? And they're also episodic and they have multiple other platforms that they're working on. So it is a bit tricky to try to get their attention like you would do in a traditional healthcare system where I say, okay, will the docs in the ortho hates this? Yep. All right. We're meeting with ortho because we have a meeting every Friday at so-and-so's. So I'll go to that meeting and get input from all those and we go from there and you find the strong personalities and you figure out how to negotiate, deal with this, yadda yadda. You do that well in these kind of environments. That's not so because you have like a lot of different docs in the platform and they're going to and they make their money. I mean, you know, they get compensated with time. And so I'm going to ask them for an hour of the time to tell me about something in their software. Most of you know, that's just not a, you could try it. You know, I tried it, but they weren't taking they, weren't buying. So and once again, it was a lot of white noise, not signal. And that's what happens whenever we get the white noise. This docs are complaining. And you're not quite sure if we should put how much validity you put on it. Right? So like when we were in those situations, then we have no hard data. I'd say it's almost. I remember when we, remember when you, we were working, we were practicing in the neonatal ICU. Right. Okay. Those babies were so small, right? You couldn't really examine, they’re under saran wrap and all this protection and intubated and things like that. But the data was coming out. You saw how they did overnight. You saw the labs, right? You saw the KB, right. You saw the op that came out. Look for retinopathy, prematurity, all these things. Well, we had to go data. So that's basically our approach here. We want hard data. We pulled the pap signal data, which is like Epic's ability to track phobias in a way. Right. And back to Microsoft. So let's get data and see where are the docs getting bogged down? What valleys and crevices are they getting bogged down in so that we can then see, oh there's something we could do on this side that will decrease their friction? And so that's what we did. We spent like maybe a whole month just combing through data, the notes they used, the navigators they were using, the reason for business they were doing, what was the encounter diagnosis, what were the measures they were giving? And then what we did is, okay, now we have hard data on what they've been doing for a year now. Let's look at the current state. We'll actually look at current state first. The current state was there was a lot of docs that were ordering medication, they would then have to add like ten milligrams or something like amlodipine. Okay. In a lot of pain. Two milligrams almost. What you just start off with, you know, whatever. So why should they have to pick that? You know, just find those things that are common, the saber click, and this is what I call the Lord's work because really detailed and if done right, no one will notice. That's what sucks about the work, because you don't get the kudos, right? You know, hey Dr. B, thanks for making this better. No, if it's done right, it just works. Almost like when Apple iPhone update and something just cool. That's cool. You don't call Apple, say thanks. You’re like, you should have done it before. So it's kind of a thankless job when you approach things like this. But that's what we've been doing in the past. And so honestly, tomorrow, what’s today? Tomorrow we have a whole pack going in and the Key Care that's going to help alleviate a lot of some of the white noise. And we're going to be measured before and after to see the benefits of things like that. And so the goal is if we make this blip on the right, we want all docs that are virtualists to comment on this and be like, Hey bro, forget those other ones. T care platform is easy. We get click, click, we're done. Get out quick. Looks like we're done and it's epic. That's what I'm going for when I design things. I want it to to crush, I want docs to choose Key Care because of the platform, you know, because they know they can get in and get out. What studies have shown is that nurses would pick, a graduating nurse will choose a healthcare system based on the EHR. Like, that's crazy. But also it's a great market differentiator and in Key Care where our platform is the product, part of it. We also get the medical group. So kind of cool.

Dr. Craig Joseph: Yeah. It's funny what you said about, you know, Apple products and their design and your work as essentially an informaticist who helps design things to make them work. Not only do you not get kudos, often you get yelled at, right? Why did you change this? I hate this. I liked it before and this is horrible and I'm never going to be able to continue to practice medicine. And then you go back two weeks later and like, hey, how about those, that change that you said it was horrible and that you could never use it? And most of us will be like, yeah, I don't remember, what what was I complaining about? I know I've certainly done that on my iPhone. There's an app, it did updates in the middle of the night. It's horrible. I hate it. I can't figure it out. And then two weeks later, if you sent me an email like, Hey, we're going to put it back to the way it was, I'd be like, I don't even know what that is, right?

Dr. David Butler: That’s it.

Dr. Craig Joseph: So we humans don't like change, even if the change is better for us. And it takes some time to kind of get over that.

Dr. David Butler: That's a, I don't know, as a, this what I’ll say, you can cut this from the podcast later. But I think as a pediatrician, you know, really this well, was as pediatrician, certain patient types, especially those that we deal with that, personality types, you know, or as an adult person, personality types of change, type A. You know, we know like, this is the medicine for you or this is a procedure you need. When you look in their eyes, you almost feel like they know it too, but they're just not going to get themselves to do it, you know? And so I think that's all change is hard, you know, for everyone, especially when you have change before or I because they said change and you do and then you get by, okay, You're not going to be willing to change again unless you got some guarantees. And so I tell a lot when I counsel on, I advise third party start ups. This is one of the first thing I said, Whatever you do, just remember you're going in with a tool that's for docs. But these docs have a lot of antibodies right now to bad technology. Okay, so if they're not, you better really come with it and you better stick the landing. As I say, the mixed metaphors. Right? If your software, I better stick the landing the first time and you just have to do it, you know? And so I have to kind of make sure they understand, like the action not just going to be, this is awesome. Let me add that to my workflow. That's not how it works. If it solves a need and a seamless and frictionless, they'll take to it like a fish to a hook, right? But if it's not, don't get upset. I don't know why the docs on the doctors need to do this. No, no, no, no. We're 20, 23, 2023. No longer is it the docs fault. It's a software fault. Now. Sorry, we're done with docs. Okay. So I mean Halo, I talk about Halo. You design software the right way. It's easy. You do it, you put it, you make, it's how our brains work, and you know Netflix, when we look at Netflix, we look at anything we design, anything in the world. Well, there's Amazon, Netflix, whether it's Uber, Lyft, these apps, the United App, use those apps or other like shopping apps, things like that, those are examples of how it should be and that what docs are getting used to over here where we ordered things on Amazon, right? We order things on Amazon?

Dr. Craig Joseph: I've never ordered anything on Amazon.

Dr. David Butler: Well me either. Right. But I automatically choose on the EHR. My point being there's a basket, there's a shopping basket concept. You get this, you put it in a basket, do things like that. There are things that we should be incorporating that are industry standard. I remember back in the day I would always coach Epic's developers, I was like, Look, they want to go all creative sometimes, like stop, make it like Microsoft already made it because they've already got our brains all right here. So piggyback on that, you know, or things like that. Like there's a term, is it skeuomorphism? You know what, I think that's like when you.

Dr. Craig Joseph: Make something look like the real world. Yeah.

Dr. David Butler: Yeah. I think Apple Notes try to do that with the yellow and the lines. Or One Note will do that. Sometimes I try to make it look like a legal pad when you don't really need lines like a legal pad. Right. But it helps humans get over the hump sometimes. So yeah, I think using some more of those would probably be pretty cool. I don't know all the words, all this. I just like to throw out stuff sometimes more.

Dr. Craig Joseph: Yeah, same. Same. All right. Well, Dr. Butler, as we get near the end of our episode, we always like to ask our guests if they have some examples of design that they think, or products that they think are designed so well, that they bring them joy. And so are there some things that are in your life that you think are designed so well that they always make you smile when you use them?

Dr. David Butler: Bring me joy. Make me smile. That's a lot. Craig. I got some funny friends like you, so I'm like, I don't want to compare product to somebody that’s gonna make me laugh like you. So I'll rephrase it as products, when I use it, I don't think about it. Right?

Dr. Craig Joseph: Fair enough.

Dr. David Butler: Well, because if I have to think about it, then it's not enjoyable. Right? I think it’s an old book, Don't Make Me Think, it's a guy named Dave Clark. Don't Make Me Think. He wrote this book and he's got a, I give it to all my analysts most when I work with them because this is about software. This is not like this color should always be this, okay. Top level should always be where eyes go, you know, things like that. Just principle, design principles. And so I think about when I think of software and then that book design of everyday things, you like that one as well. Right. I think you mentioned that a couple of times, on your podcast. So I think the thing that brings me joy now, I think about like I was in the closet, my, you know, my tech closet, the ridiculous cables everywhere. Right? And I'm always going in there. I don't feel like organizing because you got this. And I look, the usb-a this, and this lightning this, and the usb-a this in something else, yeah, you know like the ends don’t match and so when I was in that closet I realize like when I saw a USB to HDMI cable. Right. So I saw this HDMI cable and soon as I saw the HDMI cable end, I knew the the other was the same. I thought like, perfect. I love this cable. I love cables like that, there's no decision to be made, right? This HDMI looks like the same. And that's it. I knew upside, like, USB 50/50. You're doing it for chance. No. And so I think that's one example.

Dr. Craig Joseph: It's interoperable actually. So I mean it's actually funny that you say that, right? It's interoperable and you can't put it in the wrong way because there's some transparency about how it's how it works as opposed to your traditional USB cable where, you know, 50/50. Good.

Dr. David Butler: Like you could literally break that thing thinking you got it in the right way trying to push it in. I don't know, but I'm glad. Yeah. So that's one. Also the other day I was in the grocery store. It's called out here. I think the East Coast has Wegmans, down south they have Randalls and North Pacific Northwest, they got Publix. I don't know, somewhere. It's a grocery store chain. There's a software that allows you to, you know, when you go and they want your phone number to get discounts, get you in the matrix, that's fine. I'll give them a no. I'm in that matrix. That's what, the benefits finally outweigh the risk. Okay. So now because when I open the app, it knows all the things I bought before, right? So I can easily add it. I mean, all this when I, you know, of course I use the Instacart and all that other stuff, but I don't, I like to walk the grocery story to get exercise, right? So the app is really slick because what it does, there's a sub feature now, they need to make it more prominent. But it says by aisle, aisle one, aisle two, aisle three. So it breaks up the list into the aisle so that I could be more efficient just going through the aisles that I need to go through. So I thought that was super smart because it has to be tied back into the supply chain, right? Like what's coming in. And so just organizing it for users, pretty slick. I think I saw a Instacart teenager running through using the same app and so I don't know, I thought that was pretty slick design and it makes sense and it serves both sides. It's not just one side for the store, so this is a win win. So yeah.

Dr. Craig Joseph: Well, I like your definition of, you know, good design is design that fades into the background. I don't even, I'm not even thinking about it. So it doesn't particularly bring me any kind of of emotion. It just works.

Dr. David Butler: It just works. It just works.

Dr. Craig Joseph: Well, speaking of just working, thank you, Dr. David Butler, for joining us today. Really appreciated the conversation, had a good time and I look forward to seeing what you're going to do in your young career, what amazing things you'll do in the decades you have.

Dr. David Butler: Well, I hope you ask me to come back, and I'll update you in maybe three months. I think three or four months, it'll be really cool. Follow up to just say, Well, did you say what's going to happen? Did it happen? And that way I can eat crow or are you going to sing my praises? I don't know.

Dr. Craig Joseph: Fair enough. We'll have to see what happens. All right. Thanks again.

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