The Challenge of Providing the Right Data at the Right Time - Jake Engle, Senior Director at Oracle Cerner and Dr. Sam Engle, Pediatric Endocrinologist at Children’s Wisconsin

Michael Carrese: Hi, everybody. I'm Michael Carrese. To the uninitiated, interoperability may sound like a surgical term, but it actually refers to how electronic medical records and other technologies used in providing care communicate with each other. The goal, of course, is seamless communication to improve efficiency and quality of care, but that's obviously a big challenge. 

We have two guests with us today to help us understand more about this important part of healthcare delivery. Jake Engle is senior director and business developer at Oracle Cerner, a supplier of health information technology services, devices, and hardware in use at more than 27,000 facilities around the world. And for an on-the-ground perspective, we're joined by his brother, Dr. Sam Engle, who is assistant professor of Pediatric Endocrinology at Medical College of Wisconsin and a pediatric endocrinologist at Children's Hospital in Milwaukee.

Thanks very much to both of you for being here today. 

Jake Engle: Thank you very much. 

Dr. Sam Engle: Thanks for having us. 

Michael Carrese: This actually marks a first...we've never interviewed siblings together on Raise the Line in 367 shows, so I hope you feel special. I'm interested in learning more about you because you both essentially share the same goal of better patient care, but you're coming at it from different places. 

So, Jake, why don't we start with you. Tell us how you ended up on your career path and what you do on a day-to-day basis. 

Jake Engle: Sure. Thanks again for having me. I think it was interesting, when we first were approached to do the podcast, it was, you know, “talk about interoperability from a vendor technology perspective.” And I think that's really just a part of the equation, so I'm thankful to have the opportunity to have this conversation with my brother here. We both obviously grew up in the same house and then just came and attacked this from vastly different perspectives. 

We have a middle brother who's actually an optometrist, so he's getting the short end of this particular conversation, but we'll make it up to him at some point. 

So personally, I've always been interested in health and wellness with an undergraduate degree in health promotion, but a minor in business. My first job out of school was in running corporate wellness programs for an investment firm here in Kansas City. I often tend to lean toward the business side of the equation and then went back and pursued my MBA. So, the combination of passion and education -- probably not as good at science as my two brothers -- but that education brought me to Oracle Cerner.

In my time here, I spent my first six years working with home health and hospice agencies, large and small, traveling across the country. It was a great, great experience to kind of see things in action. I then spent six years building a team really from scratch to enter the Medicaid market, which was a new market at the time for Oracle Cerner. We focused on bringing innovation through data warehousing and analytics -- population health type work -- to state Medicaid agencies, including the CHIP populations, homelessness and other areas of need. CMS continues to push and incentivize those programs for innovation, and we felt like there was opportunity for us to add value there. 

The last two years have been on our interoperability team, which we'll talk about in a moment, and I focus on our open developers which are independent software vendors or engineers, coders, or companies that create applications and connect via FHIR (Fast Healthcare Interoperability Resources), APIs, which stands for Application Program Interface -- which is really a way to connect one system to another. Every piece of technology that any of your listeners have today use APIs all day long, whether they know it or not. 

My current role really allows me to view healthcare from the outside-in with our goal of facilitating data exchange where it's needed the most. 

Michael Carrese: Well, that's quite a broad background to bring to all of this. Pretty fascinating. And, Dr. Engle, what's your career background and story, and why medicine? 

Dr. Sam Engle: Yeah, pretty easy. Initially, I was diagnosed with diabetes in high school and had really great care from a family practice doctor in our hometown, and so had that interest in biology and science. I then ended up going to medical school, and in second year of medical school I did a pediatric rotation and thought, “Okay, I definitely know these are my people.” Peds/endo then fit together because in endocrinology, the main people we take care of are kids with type 1 diabetes. There's a whole other group of people with other sorts of endocrine issues like that as well, so I'm like, this is a perfect fit. And so after residency, I did my fellowship and have now been on staff here for about five years. 

My current focus is I do a lot of medical education with our residents, students and fellows, and then also I'm involved with the transition of care for our type 1 diabetes population to the adult world. I’m also now more involved with thyroid cancer pediatrics.

Michael Carrese: And are you a tech guy as well? 

Dr. Sam Engle: As one of the younger people in our group, I have become that, whether I wanted to or not. So, I'm becoming that as just as a product of the environment.

Michael Carrese: Gotcha. So, Jake, perhaps we can set the table a little bit here on interoperability. What are we talking about exactly and why is it so important to patient care? 

Jake Engle: Yes, good question. I've heard interoperability described in a number of different ways, even on some other podcasts that I've been on in the last couple of weeks. Ultimately, it's really a term like population health where it's broad in nature but can mean many different things to many different audiences. I think that's okay, because ultimately what we're trying to do is solve healthcare needs by providing the right data at the right time, and the way to do that is to interoperate it among systems. So, ultimately we have the goal of enabling providers to have complete data to support complete workflows, and then additionally, the ability for patients to be able to access that care and data.

There's more and more desire for patients to access that. In some cases, it's very clear in how they would use it. In other cases, it's not. Areas you might be familiar with would be the Apple Health records on iPhone. It's a company we work with on a day-to-day basis, and personally, it is a bit rewarding to have my labs drawn at a health system that does not use Oracle Cerner and see it on my iPhone in a minute's time via an API. So that's just one of the many examples. And, of course, I'm able to work for a company that really kind of embraces the openness and working towards creating a truly open ecosystem. There are some ways to go with that. We'll talk about that in a moment. But as your listeners know, a lot of this is much easier said than done.

When you say, why can't this system just talk to this system? You know, the data required to solve these challenges, number one, is never -- nor will it ever -- be contained in one HER. It's going to be all over the place. It's going to be in public health access databases. It's going to be in payer records. It's going to be in niche commercial products that solve one workflow such as genomics, which may not have a natural flow into the data EHR. Some may, some may not. Right? So it all kind of depends. And if it doesn't, how do you get that information in there?

Many of these use cases fall under interoperability. Oftentimes we've had a conference or something, and companies will come up and say, “Hey, we want to partner with you. We want to interoperate with you. We want to integrate with you.” That's great and we’re interested in having that conversation, but really we want to know what workflow, what problem are you trying to solve or to understand how we invest in your resources.

Some examples that the audience may be familiar with would be like the health information exchange. So, we created those networks and those networks continue to expand, and ultimately, I think they'll start to begin to merge. Prescription hubs to get that within the native workflow EHR. I mentioned payer networks. That could be Social Security Administration, that could be Medicare. That could be private insurers, all which add burden to the system. You know, we can talk about if we agree with the way it's all structured - but if we're operating within the balance of today, it's important to understand, OK, in today's world and in the near future, I need to be able to facilitate this exchange. 

Additionally, I had some calls this morning with some folks interested in clinical trials and how to serve folks up in the native workflow, how to get that information back and create that type of efficiency within that problem, which doesn't seem like a core EMR problem, but it's a interoperability problem to solve for all of healthcare. And finally, some public health reporting, to name a few. 

There are different versions of this. They can often differ at the state level, which is not often ideal but that does happen. So, we have to be able to adjust for that. And then as we expand outside of the U.S. -- typically the U.S. is leading the way in terms of standards -- but other countries are starting to lean into these. They have other similar challenges, different ways they provide care at a local and national level. So, kind of all things fall under that umbrella of interoperability. I think it's important when you start there to quickly identify what are we really trying to solve and then move forward. 

Michael Carrese: So, from the physician perspective, Dr. Engle, your brother mentioned providing complete data to support complete workflow. Talk about that in real terms, you know, on the hospital floor or in a clinic. What does that mean for you as a provider? 

Dr. Sam Engle: Yeah, it's a little different because for me it's there at that moment. I want the patient's data -- that prior workup they've had, prior labs, prior imaging, prior notes, if that's possible -- to find out what's been done so we don't have to kind of reinvent the wheel or create just wasteful spending by repeating labs or imaging that's already been done. 

This happens a lot in pediatrics in particular because there's not as many providers, especially specialists. We get referrals from all sorts of places, and some of these are small communities. There are cases where somebody moved across country, and so there's a lot of variability with how we get that information. If I can see the labs, see imaging, possibly see other notes to see kind of what's been going on with this patient, then that lets me spend more time in the patient's room instead of tracking all this stuff down and actually talking to them about the problem at hand and then letting them talk a little bit more. 

So, that's where I feel like it helps me the most. When I go in there, I'm prepared, the family feels like I'm prepared, and then we can focus on the next steps rather than still kind of tying up loose ends from what's been done, or repeating things. Especially in kids, you never want to have to repeat labs if you don't need to. I fee] very strong about that. And, again, unfortunately, sometimes with these community hospitals, they don't have the resources or the same EMR, so we can't get that data. It gets faxed, and sometimes that gets delayed or scanned in incorrectly, and so there can be errors with reading that scan or things like that. If it's a big pile of paperwork, it's hard for me to search for key terms. In the electronic health record, I can, “control-F” and I can find certain things that I'm looking for specifically.

So, as a receiving provider those are important things. But then also as a referring provider to transition my patients to the adult world, or say their families are moving to a different provider, if I can have my notes very clear to them, they can go back farther. We'll send a transition of care document with the most recent labs, but sometimes you want to see more of it, and you don't want to have a hundred pages of something. You can search things way faster through an EMR kind of system that allows you to have that function.

So those functions, I think, make the patient's workload easier, so they're not on the hook for being able to have to track every single thing that they have had done, especially if they're a complex patient.

Michael Carrese: That all makes perfect sense, I'm sure, to people listening. I mean, for a physician or any other provider to have the complete picture before they meet with a patient, and the other things you mentioned, that's a great goal. So, where are we at, Jake, with realizing that goal? What's it like out there in the real world meeting that standard? 

Jake Engle: Great question. Big challenges to solve. You know, in my roughly twenty years in the space of I think about seeing things that have been developed that at one time seemed impossible, and they've come to life. For what's ultimately possible, I think we're still really in the idea phase, and oftentimes we get our ideas as companies, as individuals, as problem solvers, by looking at things that currently exist. Individuals see technology and standards that can make the tasks in our lives easier on a day-to-day basis. Many people will engage in that all throughout the day, depending on how they want to engage that. 

So, I think the healthcare systems are a bit late to the game. It's a different type of game. It's much more complicated. There's lots of regulations, and some people argue against that fact. But, for instance, our father is going through a very personal, very complicated healthcare journey himself, and he's in and out of multiple clinics and facilities for biopsies and the rest. I had a chance to accompany him to his latest visit, and I kind of watched all this stuff in action. And, you know, the goal is to make it as seamless as possible but as you go through there, if you really kind of look at the workflow of everything that goes on in a visit -- and this is a pretty complicated visit -- it has come a long way already. I think there's a lot further in which we can go. 

A couple examples of where we're at today -- just even in the last maybe four or five years -- would be the advancements of the SPIRE standards. So, the HL7 (Health Level 7) community. Really their goal is to focus on standards. Without standards, it's very hard to exchange this data. It creates all the extra lag for every example that we just talked about. But as those continue to advance, as different versions of the U.S. core set of data gets produced and are required for certification and such, you know, that will help things such as those SPIRE-enabled applications that launch within the native workflow.

So, if there's an EMR system that cannot provide everything natively that, you know, Sam may need for his day-to-day care, and their niche is on pediatric endocrinology, and they have decided as a health system they absolutely need this in their workflow, the standards that are taking place now and some of the concepts that are required exist to go help them move forward. 

Oftentimes, we get to the point where that falls short, and they say, “Well, that data meets almost everything we have, but actually to make it work really well, we need to follow up on seven, eight, nine, ten things.” And those things are much harder to surface because there's not yet a standard, and it's kind of often buried deep within the EHR. So, I think that's kind of the challenge that we have remaining...is to really kind of surface that up and then make it scalable.

One of the things that we're currently focusing on is eliminating the noise and filtering of duplicate records. So, with the progress that's been made to date, you can see where almost ten million records can get shared across from system to system. Currently, we're working to really scan through those, and oftentimes it's ninety nine percent duplicated information. So, how can the system identify the 1% and then write it actually into the chart as opposed to I've identified the 1%, I'm looking at one screen, I'm looking at another. That's OK, and that's a nice step, but you've got to really get it to the point where it's fully integrated. 

And then finally, you know, the healthcare data standards, cloud technology, AI, ML -- all the other buzzwords that are out there -- and most importantly, government carrots and sticks, continue to advance at a pretty rapid pace, which is long overdue and needed. So, as these come into clear alignment, many of the challenges that Sam is mentioning can and will be solved.

Michael Carrese: Dr. Engle, have you seen this get better, let's just say, in the last five years? I mean, I used to work at an academic medical center and I remember our providers complaining about how many times they had to log out of one system and back into another system and that sort of thing. Has that gotten better?

Dr. Sam Engle: Yeah, I think it has. There are always people that stick to the old way they've done things. But when I went into medical school, I was in the advent of some of the earlier, not as polished, EMR systems when a lot of people were still doing paper charts. So it was interesting getting to see providers switch over those gears of going to the technology. Even in the past couple of years for us, we've now been connected through our institution with other institutions. I can look at the records from outside facilities without having to get them faxed over, and so I have increased ability to retrieve that information, which has been helpful. So, yes, I think it's definitely improved. There are constant updates -- which I think all providers kind of grumble about because they get used to one thing or the other -- but then you kind of get used to it and then incorporate that into your daily practice. But definitely, I feel like it's improved. 

Michael Carrese: I'm just curious about your relationship. I mean, are you, Dr. Engle, kind of a focus group of one for Jake to tell him, “Hey, would you guys please figure something out here because it's driving me crazy?”

Dr. Sam Engle Yeah, we have some interesting conversations. Not always, you know, I see things from a very different perspective. Our brother does too, from his optometry perspective. So, we have some healthy discussions about this because sometimes we feel like, “Oh, you don't get it because you're on that side and we're on this side.” But even talking today, I've learned more about how you have to get everything kind of linked up, and it's not an easy solve, that's for sure. 

Michael Carrese: Oh, absolutely. So, as I think you guys know, we have a lot of med students and early career health professionals in our audience and I'm wondering if you have some advice for them about how to approach their work, particularly through this lens of interoperability and working with so many different sort of IT resources and assets and systems. Dr. Engle, do you want to take a crack at that? 

Dr. Sam Engle: Yeah, I think just like embracing it is going to be probably the most helpful thing.

As a med student, I was fortunate to get that NICU baby transfer that had 300 pages of paper that I'd have to go through and sort through, and using technology to search faster, smarter...it's going to decrease your workload. Things like retrospective chart reviews that you might do with an attending for a research project...that's another good way to kind of get into the system, learn how to navigate the system. Those kind of things I think also help, especially if it's a newer system that you're coming to as your training progresses.

Michael Carrese:  Jake, what would you add to that? 

Jake Engle: I echo that and simply put, lean into it. It doesn't mean you have to believe in everything that it does and just totally go with the flow, but there is a sense where, you know, there's value in watching and learning how it works not only for yourself, but also how it works for your care team and how your patients interact with the technology and the tools provided. 

I've had lots of different corporate experience where I've worked with HR tools, sales tools, finance tools, legal tools, contract review tools, data tools, all sorts of that stuff, and it is important to -- even in a corporate setting as kind of a weak analogy here -- to understand what the person approving your expense report is looking at. When you're trying to get the information in and you're frustrated between the two, it's important to have a respect of what that other person is challenged with. 

Long ago, I implemented travel and expense systems and then was a user of them,

and that's kind of a good way to bond and hopefully get those expenses through. But that can be used in a nurse provider, social work, caregiver type of dynamic as well. Even in the home health and hospice world where you have social workers, PTs, OTs, STs out there, you've got to get over to your medical director and the rest, and it might be in a nursing home, might not be in a nursing home. At the end of the day, somebody looking at the data can be frustrated. But I think it's important to really understand how did this data actually get here? What is the person encountering in the day-to-day of life that was enabling them to be successful and what challenges they have inherent in that system? 

One example in which we made this true to form was when I worked with the home health and hospice groups. We required engineers, support staff, professional services or consulting to conduct a ride-along with caregivers to see the product in action. This is maybe ten, twelve years ago. What would happen is you had a very heavy, thick laptop with a big battery that was not connected to the internet, and you'd open this up, and oftentimes it would take a couple of minutes to load. And then you’d realize that it’s easy to sit behind a computer and think “it's a couple minutes, what's the big deal?” But it's different when you're sitting in the room or a house. It might be a very nice house, or it might not be a very nice house. You may have plenty of room, or you might not have any room to try to bring this other device and see how every one of those seconds and steps and clicks and all of that matters. 

The point here is just getting that hands-on experience. You don't have to do it all the time, but I think a regular check-in on that is important. What that did ultimately was provide great perspective, even from somebody answering the phone in a support call. The queue of support calls can be endless, but when you're actually trying to solve a problem and you've got that experience from a recent encounter, a recent visit, it really does make a difference. So, I would encourage you -- whether you're Sam and you're kind of taking the lead or you're somebody on his support team -- to understand the challenges and technology workflows of what they're doing. It brings it into perspective, and then you kind of keep that in mind as you deal through the good and the bad of providing care. 

Michael Carrese: Does that make sense to you, Dr. Engle? 

Dr. Sam Engle: Yeah. I think the overall goal for all of this is to really improve patient care. As a provider, you need to realize what the patient is seeing, what the deal is. If you're sitting there clicking through stuff for a long time, that perspective helps us because that's what we're trying to improve...that patient care, both in the room and overall. So, yeah, I think that that makes sense. That team approach of seeing what the role of a medical assistant, or the nurses, or what your role in clinic is -- it's all very different, completely different. And we practice that. We've actually gone through and shadowed what everybody does in that visit to help make those visits more efficient and try to make sure that we can understand why certain things are needed or what we can kind of streamline. 

Michael Carrese: You know, I think I'd be remiss if I left without asking about generative AI because it's just come on like a steam locomotive recently. Does that have a role in what we're talking about? Is that going to be a way to help with interoperability or not? What do you think, Jake? 

Jake Engle: This is where the two perspectives can be widely different, right? I think there is value in the potential if used correctly. There are a lot of scenarios in which things do have trends and can be repeated and can be automated, and evidence can and has shown that. But, you know, it's not always black and white. So, there has to be a balance of it. I would imagine that Sam will weigh in here in a second. But, you know, from our perspective, yes, there is value. We're actively teasing that out as we speak. I had conversations about that this morning. How do we use some of this and how do we get it into the workflow? Things like alerts are mentioned, and that's a very sensitive topic to where you've got to minimize alert fatigue and get it in the right place at the right time. So, I think there's a lot more to come there, but it's an active part of day-to-day conversation on our end. 

Michael Carrese: So it might be something you can harness in positive ways if you're careful about it?

Jake Engle: Correct.

Michael Carrese: What do you think, Dr. Engle? 

Dr. Sam Engle: I think there's potential benefits to it. Some of the AI stuff makes me nervous in terms of nefarious things or denying things and stuff like that. So, I get a little nervous about that. But there's definitely some systems in our regular workflow that can probably benefit from it. And again, without it being black and white and kind of getting that patient input, there could be some subtle variables that maybe you might not get from simply just pattern recognition.

Michael Carrese: I have to say I don't envy providers because it just seems like the amount of tools coming your way all the time -- leaving aside generative AI -- but all the other AI, all the data crunching, and just the massive amounts of stuff to learn about whether or not this can be incorporated into your workflow and your practice must be a little overwhelming. Do you feel that way?

Dr. Sam Engle: It can be. An example in our diabetes practice...there's been huge advances in diabetes technology in the past five years. We're constantly having to learn the new pump technology, which might be different from one pump to the other, because we want patients to have them. They have great benefit. But it can be quite confusing to know what the subtle difference is there. Luckily, working at an academic center, we have very frequent discussions and time to do that. So, it doesn't feel as overwhelming because I'm surrounded by so many smart people.

Michael Carrese: That's good. So, we are just a couple minutes away here. I wanted to give you the same shot we give all of our guests, which is to give us some direction. We're a teaching company. We love to fill knowledge gaps. Is there a topic you think Osmosis should make a video about or a course about to fill a gap in knowledge that's of particular concern or interest to you? Jake, why don't you go first? 

Jake Engle: Yeah, I was thinking about this, and I'm big in the context and a very visual person, so I can understand the picture, then I understand where we're going, and the details will come and fill in the blanks. 

We referenced our dad earlier, and he's going through his journey today. But often what's missing there -- and I did some high-level searching for images or diagrams on this -- is a true diagram or a flow that a patient can follow that helps guide them. When I search for this, what often comes up is, “Hey, if you use this insurance, then you follow these steps.”  Or everything is very siloed. 

It's a complicated problem to solve, but I think we need to move away from all these diagrams, and we're guilty of this as well. Here’s a diagram of a patient in the middle and fifty buildings behind them, and it's all patient-centered care, but there's really no way that clearly guides them when to go here, when to go here, how do they move from this one to this one, or do they go from here and jump over here? So something along those lines.

It probably has to be a bit use case because it's a giant problem to solve, but it's a little bit more true in terms of soup to nuts and how that patient-centered care and how that navigation is needed. Why I think that's particularly important is you think about who's advocating for that person, and some people are better self-advocators than others. Some people cannot do it at all. So, it has multiple audiences when you're trying to take care of that actual patient who may or may not know how to do those things for themselves. 

Michael Carrese: Well said. Dr. Engle, you get the last word. 

Dr. Sam Engle:  You know, my thought is very similar. Obviously, I'm ped-skewed, but that transition from a pediatric practice to an adult practice -- because we know there's this whole concept of emerging adulthood where you're not really a fully functioning adult at eighteen, even though some of the laws may suggest that -- so that navigating of where you go, who you see is important. If patients have gaps in that care, things can go undetected and you miss certain things that could occur. 

There are transition guidelines and documents to help with that kind of stuff, but identifying for these teenagers who they need to see, when they need to see them, why they need to see them would be great. There are applications or using Apple Health to put your health data on there so then you can have that as another resource for when you do go see another person and you have that information. 

Michael Carrese: So, illustrating the patient journey, it sounds like, is the unifying theme there. That's great. We'll work on that. But for now, we're going to have to leave it there. I want to thank you both for being with us today. It's really been a fascinating conversation. 

Jake Engle: Thank you very much. Appreciate everything you guys do. Appreciate the providers and caregivers that are working with the tools every day and do not envy the use challenge. I appreciate all the support. 

Dr. Sam Engle: Thanks for having us. 

Michael Carrese: I'm Michael Carrese. Thanks for checking out today's show and remember to do your part to raise the line and strengthen the healthcare system. We're all in this together.