Dissecting Digital Health — with Grahame Grieve
Grahame Grieve has carved out an ‘accidental’ career in health informatics, where he has his hands on levers that are significantly shaping the future of digital health across the planet.
This is the full transcript of a lecture given by Grahame to students at the University of Melbourne. We didn’t originally plan for it to also be a podcast, but I felt Grahame’s lecture was so good that others should hear it. I asked Grahame to reflect on his career and personal journey and to impart words of wisdom to the health informatics students who were intently listening to his every word.
This is Grahame’s story….
Guest: Grahame Grieve, Health Intersections
Host: Dr Louise Schaper, HISA
Tweet Louise @louise_schaper Tweet Grahame @GrahameGrieve #FHIR
Production: This podcast is produced by Ivan Juric
Show Notes
[2:13] Grahame Grieve opens his lecture to the students at the University of Melbourne with a captivating summary of his successful career in healthcare. Once his animated introduction gets the students listening, Graham goes into depth on his journey to where he is today.
[5:04] Graham shares his serendipitous journey towards a PhD at Melbourne Uni on diabetes and lipid metabolism, which led him to even more unexpected career paths — most notably, in programming.
[8:20] Graham delves deeper with the students on his career programming as a development lead for the company. His talk moves towards how his work became driven by his passion for healthcare informatics.
[11:30] Eventually Graham takes his skills and knowledge acquired from his years as a leader, and talks about the beginning of his consulting career. Through his time consulting, he sees a lack of workable standards, and is pushed to make a difference.
[14:05] Graham concludes his career path story, noting his work ethic and passion being main drivers. He then goes on to explain FHIR (Fast Healthcare Interoperability Resources) and its ground-breaking role in healthcare.
[17:03] As asked by Louise, Graham continues to talk about career, and reveals his unconventional path, and outside-the-box thinking. Through his personal story, he encourages the students to think outside the structure of the system.
[18:59] Graham emphasises the crucial need for informatics to be integrated in education as a first step. He discusses the human nature of tech, with health informatics being primarily about people
[22:00] Graham brings his lecture to a close, talking about why, as a community and team player, a PhD didn’t fit his goals. He attributes the impact he’s made being due to focused on contributing to community.
Full Transcript
Grahame Grieve opens his lecture to the students at the University of Melbourne with a captivating summary of his successful career in healthcare. Once his animated introduction gets the students listening, Graham goes into depth on his journey to where he is today.
[2:13] So, I don’t have any slides, I’m just going to talk. You’ll just have to listen. I wake up every morning and think I’ve won the lottery. I have a job that pays three times as much as I thought I’d ever have. It could pay heaps more if I bothered. I get to travel the world and meet politicians and famous informaticians and institutions that are the intellectual cutting edge of medicine that ask me to come visit them. I have got my hands on this standard, that will define the future of healthcare data. I get people asking me every day for opinions, for consulting, for advice. I am doing something that I really believe is for the good of the world — as social activism, I’ll come back to that — and I get paid to do that. I get paid to do that by big companies whose heart is getting ripped out of them by what I’m doing. How good is that? [Laughter]
And my daughter says to me, “Dad you’re a hero.”How good is that? OK. So that’s what I do, I wake up every morning thinking man I’ve won the lottery, to do that.
[3:30] So, I’ll tell you about how I got to where I am, because I think that it’s a path open to any of you, if you want to. So, I grew up on a farm in New Zealand, a farm boy. I expected to live on a farm and be a farm boy and that was what I wanted but I wanted to be good at it. So, I went to university and did a degree in biochemistry in botany so that I could do plant genetic breeding research around getting improved crops because that’s a big deal. But there’s lots of people working on that. So, I went to uni and I did that, and I finished uni and I did what a lot of Kiwis do because I was in New Zealand, I went to Australia for a holiday. [Laughter]
I thought I’ll travel around Australia and I’ll come home and get a job and find a place. And then what happened was I ran out of money here in Melbourne and I got a job. And I just, for some reason I have no idea, I just applied for any job where it had biochemistry in the title and I ended up landing a job at a clinical lab in St. Vincent’s Hospital. And I’m like, after about three weeks, I’m like,“I’m home. This is my future. I really believe in health care.” And it’s not just a job, it’s a calling. And I’ve got to tell you that it’s kind of a shame, for what I’m talking about is, about a calling, right?
I’ve been offered jobs in banking and telecoms and travel and I just don’t care. I just I don’t care about them. But health is something really different.
Graham shares his serendipitous journey towards a PhD at Melbourne Uni on diabetes and lipid metabolism, which led him to even more unexpected career paths — most notably, in programming.
[5:04] So, I worked in St. Vincent’s for a while, but I got a job there actually on a NHF fund/NHF grant. So, the scientist who was doing the research, I was replacing him in the clinical lab and when the NHF grant ran out, suddenly I had no job. And so, the lab said,“Well we don’t want you to be gone, we can’t employ you as an employee but we’ve got slush funds that we can use to set you up doing research.” So, I ended up doing a PhD at Melbourne Uni, in the clinical school at Melbourne Uni, research into diabetes and lipid metabolism and it was kind of, in the lab still. So, I was still around the lab and still moonlighting in the lab and doing various tasks for them. I was in a team with six MDs and PhDs who were doctors, so it was extremely clinical and I was the only scientist. So, a really bad idea. If any of you ever do a PhD think really hard about who you are with. Because I ended up being the grunt worker in the team [Laughter] and you know, that was good for me because as you’ll see when I talk about what I do,
I’m really drawn to community and working with the community and investing in the people around me. And sometimes it pays off really big. And sometimes it doesn’t. And if you look at the long term and where I am now, it pays off really well.
Right? Even if, like what Chris the previous speaker said, you take less now to get more later. And man, it pays.
So, when it came to the end of the four years doing my PhD, I’m looking at it going, “I really haven’t got enough to get a PhD.” Like, I’ve done some really interesting stuff and fun stuff and I’ve learnt a lot about rigorous thinking and research. But I’ve run out of money and I don’t really have anything to write up. And then at the same time I was coming to that realisation I got an offer from a computer company, which installed the computer system in the lab, to go and work for them. And so, I took the job with them because, what else could I do?
And so, in fact my whole career is a series of total accidents.
Right?
[07:09] So, I thought I was a farm boy and ended up in a hospital by accident. Then I ended up in a computer company by accident and the clerical person rang me up beforehand, before I started, and said, “What am I going to put on your business card?” I said, “I don’t know” we didn’t agree on what I was going to do there, they just asked me to come and work for them. So, I had a business card with no title on it. And when I started the first day, I flew over to Perth where the head office was, I sat down with the boss and said, “Well what do you want me to do?” The owner of the company — who is a great, typical entrepreneur, forward thinking, risk taker — they said, “I got this project I want you to look at. I want you to go and talk to the programmers and they can tell you what they’re doing.” And by the end of the day we’ve figured out that we wanted a different course, we wanted to do it on the Web.
And you’re like, “Duh!” but this is so long ago now, that was like radical, brand new idea. And then they go, “But how do we do that?” I said, “There’s got to be some way to do this with the code base you have. Let’s go and look at some code and let’s make it work.” And by the end of the week I was the lead programmer for the team.
Graham delves deeper with the students on his career programming as a development lead for the company. His talk moves towards how his work became driven by his passion for healthcare informatics.
[8:20] So, I had done a bit of programming, programming is kind of like breathing for me, so, I end up dev. lead for the company. Development lead and then chief technical officer, which is a fancy term for development lead. Hiring and firing programmers, I had between 30 and 40 programmers working for me and I had to hire and fire; had to hire about once every six weeks and I had to fire about once a year.
And I led the Kestrals, which has software in various hospitals around here, some of which I’ve personally led development of. Which is kind of nice when I go to hospital. And I was in hospital recently and they were still using my software after all these years!
[9:26] So, in that time, what was really clear in the company is, the company was split formally into support, business analysts, technical support, relationship manager group of people, and the developer, programmer, architect group of people. But
what was really clear if I looked across the whole company was there was two kinds of people; there was the journeymen, people who just had a job and there were people who believed in health informatics — and they were the ones who had impact in the company.
And so, I stayed at Kestral for a long time developing software. But more and more of my role at Kestral was to interact with the rest of the industry, the other vendors, with the hospitals; and the more and more I got involved in standards, because standards is a really technically arcane area but it’s also the lever. Right, get your hand on the lever and move things along. So, I started contributing to standards because I contribute to community, right!? It’s about giving to the community.
And so, did that. Then gradually I was getting more and more involved and then I ended up working for the NHS as a consultant through my company. Consulting with them about why they weren’t making any progress and I just got more and more involved in that. And then there was the life cycle thing at Kestral. After about 15 years at Kestral it was time for the company to knuckle down and do hard core IT, architecture, product redevelopment, rather than informatics, interoperability, product outcome development; and I’m like, my heart’s just not in that because it’s not healthcare I.T. It’s hard core I.T. architecture stuff.
And the other thing that happens, and this is a real problem for companies, if you’re good and you’re interested in healthcare informatics, you’re interested in interoperability standards and you can make progress, you’re really hard to hold onto. Right?
Eventually Graham takes his skills and knowledge acquired from his years as a leader, and talks about the beginning of his consulting career. Through his time consulting, he sees a lack of workable standards, and is pushed to make a difference.
[11:30] One of my primary challenges was holding on to people with healthcare informatics skills, at the company that I was at. They kept getting snaffled up by other companies when I trained them up. And so that happened to me, too. And I said to the owner of the company, “I really loved working for you personally and I loved working for the company but it’s time for me to go off and become a consultant contractor and earn twice as much money.”
It didn’t last. So, I quit, still worked for Kestral a little bit and I went consulting. And in theory, if you’re a busy consultant you should be earning half a million dollars a year. No worries. Right? And people I work with regularly bring in much more than that. And so, you can — you have to work hard, you have to be good, you have to be good at people, you have to be good at tech, you have to be good at health — but you can.
[12:24] So, that’s what I thought I was going to do. But then that community thing bit again. And I ended up working for NEHTA, which Chris was talking about, and consulting with them on standards and application of standards. It became really clear that the standards weren’t working. And so, I decided, and I was chair of some committees at HL7, which is the international standards organisation, and I decided that it was time to change the game. And the thing is, you’ve got your hand on the lever. And you can change the game.
And that’s the thing about informatics and IT — is that you can change the game. And so, I did.
So, I defined what became FHIR, which I’ll talk about in a sec, thinking that it would get me thrown out of the civilisation of healthcare IT. [Laughter] It didn’t work that way, did it?
So again, another surprise, here I am running the programme doing all the things I told you about. A completely unexpected outcome. And to the point now when I go to HIMSS, which is the U.S. equivalent of the HIC meeting that Louise organises, and I have groupies, I have a tail that walks around with me [Laughter], I give signatures, selfies. Who would have thought that a programmer and standards geek would get to that point? It’s just ludicrous. It’s also entirely manufactured by the politicians there, right. They decided that I was going to be a rock-star and so I am [Laughter]. And maybe later I’ll tell you about Aneesh, who was the CTO of the White House who organised the whole thing and thinks it’s hysterically funny that I’m the rock-star.
Graham concludes his career path story, noting his work ethic and passion being main drivers. He then goes on to explain FHIR (Fast Healthcare Interoperability Resources) and its ground-breaking role in healthcare.
[14:05] So, there you go. OK. So that’s like my career, a total series of accidents that came about because I’m willing to work hard, because I care about health and because I invest in community. And it’s not magic. It’s unusual that you’re willing to make that investment, right, that you really are drawn to do that. But if you do that, that’s the kind of thing that happens, right? It’s not anything else than those three things.
[14:35] Now, a little bit about FHIR. So, FHIR is an API standard to allow data to be exchanged.
Technically FHIR is architected around the Web, so all the things you can do with the Web, the things you’re used to on your phone, are things you can do with FHIR — which is like a brand-new idea in healthcare and it’s miraculously disruptive.
Anybody could have thought of it and lots of people did but nobody was in a position to do it. Technically FHIR stands for “Fast Healthcare Interoperability Resources” which just shows you how hard it is to get a globally unique acronym these days [Laughter]. But it is globally unique and if you type in FHIR, you find my team, my community, the standard, you find us.
Louise talked about me being famous and I was thinking about it and it doesn’t make sense because I’m just the front person of a massive community who commit their whole life to the vision that I share with them — my vision. Anybody can have the vision, we share, it’s social activism, I’ve said this before; we want to change the game for healthcare. It’s too hard to get things done, it’s too hard to move information around, it’s too hard to connect systems from different companies.
It’s not because the companies want it to be that way, it’s more the inevitability of just the chaos of healthcare and information. It’s too costly and it’s killing my family and my friends, the people around me, and that is what we need to change.
I’m going to keep doing what I’m doing, as long as I can afford it; very little of what I do with FHIR is paid work, I have to get paid work on the side. But I’m getting by. And as long as I get by and until my family healthcare improves for my extended family, I’m going to keep doing what I’m doing. Because it’s about changing the game. And I’m not here to tell you anything more about FHIR, other than that.
As asked by Louise, Graham continues to talk about career, and reveals his unconventional path, and outside-the-box thinking. Through his personal story, he encourages the students to think outside the structure of the system.
[17:03] One thing that Louise asked me talk to about is career. So, first of all I told you, it’s all accidental but what I have ended up in, I am in no box. I’m completely outside everybody’s boxes. Universities come to me and say, “Well you should have a PhD and be a professor” but I don’t have any of the formal qualifications that I need even though I’m a thought leader, way out in front of them.
I don’t have publications, because I just publish everything straight to the Web so everybody can read it.
I was working with one professor and he said, “Where’s your published, reviewed content?” I’m like, “Well I write the standard. 10,000 people have reviewed it and commented to me at length on it.” “Where’s the review?” he says. “Well I don’t know. I mean what do you want?” Right, it’s all in the public, it’s all totally transparent but I don’t qualify because I’m not in anybody’s box.
I work with politicians, with senior professors, with whatever. I’m a consultant but I’m not a consultant in any meaningful way like some of my friends that I work with who actually make real money out of this business, that don’t fit in that box either.
But the thing is, it’s not unusual. The boxes or the walls of the boxes are being knocked down by the change in technology, the change in social media, the change in networking, the way finances work, the walls are all disappearing. And Chris and Damian already talked about this a bit. There is no career path. There never has been for healthcare informatics. Most other disciplines are heading in the same direction — we’re just out in front. There’s no boxes. Make your own box.
Like Chris said, stick your neck out.
Take risks. If you’re talented and you’re prepared to work hard and you’re investing in the community around you, it’s going to work out. It might be up and down but it will work out.
Graham emphasises the crucial need for informatics to be integrated in education as a first step. He discusses the human nature of tech, with health informatics being primarily about people.
[18:59]
healthcare informatics is a fusion between tech, health and management. And to really understand that, you need to have done some time in each of those things.
And if you have done time in each of those things and you’re interested in thinking structurally about what’s happening around you, that is healthcare informatics. And it goes all the way back to Claude Shannon in the 40s and 50s, thinking about information warfare, about what it actually is to have and manage information. Those are critical things and critical skills and I wish that they would teach informatics at school. It’s like critical these days, as critical as knowing how to manage your bank account. In fact, it is managing a bank account, very similar thing. I wish they would teach informatics. But then I look at the kids in the school, I’ve got daughters in school, and it’s not going to happen.
But one thing I do…they tried to get my daughter to do engineering and STEM subjects and they particularly tried to get my daughter, who is now at university, to do IT. And she said to me, “Dad, I don’t want to do IT! It’s toys for the boys, it’s bad.” I said to her,
“You don’t understand. Informatics is about people. Informatics is about having a lever over people, about managing people’s behaviour.”
And so that’s healthcare informatics. And it’s outside everybody’s box. So, make your own boundaries. So, one thing I’ve been pretty clear about and it’s one of my, which is just starting to appear more often, one of my laws of interoperability — it’s all about the people. This is about people. Tech just happens, and both Damian and Chris have brushed on this a bit, that anybody can code. I used my codes like walking because that’s the role that I play. But you can buy coding skills, right. You can go out on the market and buy someone who will program, just like that. What you can’t find, and what was my challenge at Kestral to hold onto, was people who could think about the intersection between tech and healthcare and management and information and understand how to make that flow. And if you have that, you think about that, think about it structurally, it doesn’t matter what you do, you will be valuable to somebody. You’ll be valuable to everybody in healthcare because
all of healthcare is about getting information at the right place at the right time in the right context.
And again, Chris talked about this, the actual procedural execution of medicine you can buy those skills, too. It’s diagnostics and gathering the right information and making the right decision — that’s where all the action is today.
Closing Remarks
Graham brings his lecture to a close, talking about why, as a community and team player, a PhD didn’t fit his goals. He attributes the impact he’s made being due to focused on contributing to community.
[22:00] And finally, I want to say, and I hammered away on this because it’s critical, that it’s always been my ethos to commit to invest in the people around me. And when I came to the end of my PhD, I kind of came to a bit of a crossroads with that, because I realised that I’d screwed my own PhD by investing in the people around me, the MDs and the PhD doctors around me, instead of trying to focus on what I needed to do. And when I realised that, at the end of my PhD, I was kind of like,“Maybe that was a big mistake.” But I realised that the big mistake was actually doing a PhD Because it’s not something that suits my personality, and so I had to accept that it’s innate in me to invest in the community around me. And that I wouldn’t play tennis because it’s a single person game and I wouldn’t do a PhD because it’s a single person game; really it is.
And I’m not sorry. But I’m glad I did my PhD, don’t get me wrong. I learned a lot of skills that have let me do what I do but I believe strongly in community. And
I work around me with some other well-known world leaders and lots of people who aren’t known, who are just as valuable, who believe in contributing to the community around them;
doing things like this, lecturing at university, answering questions on the Web from uninformed, un-thinking people which is, hard work. Committing to professional societies like HISA, which Louise runs, the standards organisations, the standards organisations attract people who are structural thinkers, but they have more power. One thing I’ve been trying to do at age HL7 is get a patient focus group. Like a consumer focus group at HL7. But I can’t because no other consumer organisations in Australia or the UK or Singapore or USA, none of them can get their heads around why would we engage with HL7. None of them are thinking structurally, that’s where the lever is.
And so, they’re all off in the wrong place, wondering why they have no impact. I’ve got my hand on the lever. Come and join me. But you’ve got to think structurally, right. But if you do, the thing is about committing back to the community. I know some people for whom it’s a tax, for whom it doesn’t make any sense at all to commit to community. Some people are, circle the wagons, look after the inside, don’t worry about the outside kind of people. But eventually the company starts to run into trouble because they’re not, the company itself, is not contributing back to the environment around them and it starts to become the ethos of the company.
So, always contribute to the community. Encourage people around you in your company, when you have leadership of something, your division, whatever, to do to that, to be involved in the societies and the standards and lecture and teach around it. And that is what, in the end, magnifies your value long-term.
Right, and I’ll stop there. Thanks. [25:32]
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