John Squeo of CitiusTech: In Light Of The Pandemic, Here Are The 5 Things We Need To Do To Improve The US Healthcare System

Video visits are not the answer to mitigate shortages since a physician is merely moving an in-person synchronous, one-on-one encounter to a remote connection. Asynchronous tele-health such as messaging is also insufficient. The provider still needs to dedicate time to responses which can take as much time or more than an in-person encounter. The shortages are not ubiquitous; they are related to disparities in the geographic distribution of doctors in the U.S. Shortages are more prevalent in rural areas and in some metropolitan regions, which have a glut of physician specialties.

The COVID-19 Pandemic taught all of us many things. One of the sectors that the pandemic put a spotlight on was the healthcare industry. The pandemic showed the resilience of the US healthcare system, but it also pointed out some important areas in need of improvement.

In our interview series called “In Light Of The Pandemic, Here Are The 5 Things We Need To Do To Improve The US Healthcare System”, we are interviewing doctors, hospital administrators, nursing home administrators, and healthcare leaders who can share lessons they learned from the pandemic about how we need to improve the US Healthcare System.

As a part of this series, I had the pleasure to interview John Squeo.

As a member of CItiusTech’s executive team, John Squeo leads account management, sales and partner channels for the company’s Provider and Healthcare Services market. With experience that spans 27+ years in healthcare technology, interoperability and Cloud (GCP & Azure), he has been instrumental in developing technologies that enable tip-of-the-spear care model redesigns and value-based care initiatives. John also chairs a Chicago-based non-profit health charity, which has filled the insurance gap for 114,000 local residents and was featured in the Wall Street Journal.

Thank you so much for joining us in this interview series! Before we dive into our interview, our readers would like to get to know you a bit. Can you tell us a bit about your backstory and a bit about what brought you to this specific career path?

I have been in a technology career for 25+ years but joined Hospital Corporation of America in 2004 in IT and felt that I had finally found a true mission — helping people during the most vulnerable times of their lives. I committed to the calling and spent my career working from IT engineer to CIO, then as a Chief Innovation and Strategy officer for health systems. I finally landed in health strategy consulting as a Managing Director for Accenture and now I lead the Provider market business unit for CitiusTech.

Can you share the most interesting story that happened to you since you began your career?

When my teams were going live with an EMR at a hospital, we were in the process of implementing eMAR and Bedside Medication Verification BVA when I was called up to speak with the Chief Nursing Executive CNE of the 24-hospital system. I was worried that the system failed, and our team would be criticized. Instead, I witnessed a very experienced nursing leader in tears being consoled by the CNE. She hugged me while sobbing and mentioned that the medication verification barcode scanning had just stopped her from admitting the wrong drug to a patient that could have been fatal. To be honest, we cried together and when I told my team of IT engineers and application specialists, everyone was in tears, and it confirmed our commitment to healthcare IT.

Can you share a story about the funniest mistake you made when you were first starting? Can you tell us what lesson you learned from that?

When I first began working with clinicians and providers, I made the mistake of thinking that a simple Outlook calendar invite would alone motivate them to attend an in-service or training. In the first two trainings, it was crickets. No one attended. The next time I sent out the invite, I advertised the event with paper signs at the nurses’ station, offering cake and pie. Three hours before the event, I called and texted everyone and personally led people to the event from hallways, the cafeteria, and their offices, baiting them with candy. Lesson learned: people are busy so over-communication is the key to engagement.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

My life lesson is to “find and follow your bliss.” Your heart may lead you down different pathways in life and your North Star vision may shift. But what matters most is that you find something you love and commit to it. It becomes the nucleus of your personal guiding principles. If a good opportunity comes along but it does not truly make you happy, turn it down. When you are doing what you love every day, you can’t even call it work. I have a deep desire to make a major contribution to getting the U.S. to spend a percentage of GDP on healthcare on parity with Western Europe by the time I retire around 2035. Anything that doesn’t contribute to that, I de-prioritize.

Are you working on any exciting new projects now? How do you think that will help people?

A current project reminds me of why I originally wanted to pursue a PhD in AI. We are developing a text-based conversational AI to query a structured or unstructured data warehouse in real- time for health systems. This will free people from having to write reports or use visualization tools. It will bring rapid intervention, inform next best actions, and would make the most of a clinician or provider’s precious time. It would bring the “Turing Test of AI” to life in the most beneficial way for healthcare.

How would you define an “excellent healthcare provider”?

An excellent healthcare provider is a person or entity willing to completely embrace change to improve patient access, experience, personalize their care models and who lead the redefinition of what it means to care for a patient. Traditionally, providers-built factories of services lines within centralized hospitals and medical offices in a vertically aligned network to leverage economies of scale but ignored the inconvenience to patient access and employed a one-size-fits-all approach to care delivery. “Excellent providers” are reimagining the needs of the patient as a person, considering their lifestyle personas, motivations, and social determinants of health. They are redesigning care models into horizontally integrated networks across the healthcare ecosystem including clinical drug trials, on-demand medical supplies and DME synchronized with patient discharge, consumption patterns and home delivery, pharmacy, and payer service. They are even addressing non-clinical home services like housing, meals, transportation, or supplies covered under Medicare Advantage plans like air conditioning for certain chronic patients. They are meeting the patient where they are, leveraging telehealth.

Integration across the healthcare ecosystem is also being driven by healthcare services from non-traditional market entrants such as Best Buy Health, Walmart, and Amazon in addition to traditional players. The best providers are connecting the patient to dietary, fitness and behavioral services networks with the help of digital, IoT and automated workflows.

Excellent healthcare providers have already begun their transformation journey to create flexible patient data exchange capabilities using FHIR and Clinical Quality Language (CQL), getting smart on how to clean the data to speed interventions and avoid expensive acute care visits. An excellent and personalized, “whole person care model” requires systems, data, and process integration over and above the EMR system of record to act as the connective tissue of information. But, in addition to all of that, I believe the best providers deliver care with empathy. I think it was Theodore Roosevelt, who said, “No one cares how much you know, until they know how much you care”.

Ok, thank you for that. Let’s now jump to the focus of our interview. The COVID-19 pandemic has put intense pressure on the American healthcare system. Some healthcare systems were at a complete loss as to how to handle this crisis. Can you share with our readers a few examples of where we’ve seen the U.S. healthcare system struggle? How do you think we can correct these specific issues moving forward?

During the pandemic, health systems struggled across three dimensions: 1. Labor force resiliency. For instance, when a health system’s clinicians were getting infected and their non-essential workforce was sent home to work, they were forced to use non-scalable remote connectivity; 2 The financial crush of losing their elective surgical procedures — their most profitable services; 3. Outpatient access had to fundamentally adapt overnight to a remote site of care using telehealth services.

Some of the biggest impacts of the disruption are workforce reductions by attrition and resignation, impact to clinician training pipelines, and severe supply-chain breakdowns (PPE, ventilators) to name a few. But there are some bright spots, including the acceptance of tele-health by providers and patients. COVID was also a tremendous catalyst that proved drugs can be developed, trialed, approved, and manufactured at massive scale with rapid velocity. The pandemic demonstrated that legacy service models, therapy development methods, and processes have huge opportunities for efficiency and streamlining.

From an improvement perspective, Cloud and SAAS based technology such as remote collaboration tools like Zoom, and Microsoft Teams were the heroes of the day because they are massively scalable and provided a functional experience for performing most white-collar work.

We learned, even with COVID subsiding, that companies are committed to long-term flexible remote work options for their employees with robust Cloud-based tools. We also learned that supply chains are very fragile and that we need a self-healing method to source products when our known suppliers are out of stock. There are startups building solutions by using near-time crowdsourced data and analytics to create adaptive product procurement methods which also collate data sets which can be used by manufacturers to better forecast demand surges.

Of course, the story was not entirely negative. Healthcare professionals were true heroes on the front lines of the crisis. The COVID vaccines are saving millions of lives. Can you share a few ways that our healthcare system really did well? If you can, please share a story or example.

The workforce scarcity and compressed margins during the COVID crises has forced IDNs to increase efficiencies and reduce expenses by aggregating spend and redesigning processes. Intelligent automation can improve the business outcomes in the supply chain processes which are repetitive and resource intensive. Our solutions enabled a leading provider to establish the supply chain management robotic workforce to a broader member base. We assisted in building several supply chain processes, leveraging an intelligent automation platform (e.g., equipment acquisition, inventory management, and recall management). We also helped with automating different supply chain management tasks, which saved 90–95 percent of FTE effort with 98 percent accuracy, allowing them to focus on more essential processes and were replicable at an enterprise level.

On the clinical side, provider systems wanted to have a more accurate and up-to-date profile of the patient prior to the doctor’s visit. In the recent past, the data just wasn’t available and there was no good way to get it into the providers EMR for use during the patient encounter. Now, with FHIR gaining greater adoption as both an API and a data model, the data is much more accessible and the EMRs have opened-up their APIs to ingest the rich information. For instance, Epic can display the pre-visit planned suggestions to the doctor within their EMR as an Epic Best Practice Advisory clinical decision support reminder or message. Intelligent automation presents a tremendous opportunity for supply chain organizations to enhance their value delivery and curb the cost of operations.

Here is the primary question of our discussion. As a healthcare leader can you share 5 changes that need to be made to improve the overall US healthcare system? Please share a story or example for each.

1. Simplify care journeys. It all begins with member-centric health plan design and streamlined medical management. Sidecar Health and Oscar Health are two new models of health insurance that were designed from the ground up to make a frictionless experience for a user. Sidecar is a great example of a QHP that I’ve seen that blurs the definition of in-network to provide a ‘network-less consumer experience’. A consumer just goes see a doctor to heal themselves and feel better without the hassle.
2. Default to telehealth. The next horizon is Virtual-First Products (e.g., UHG, Humana, Oscar) powered by simple remote patient monitoring suites like TytoCare.
   Foundational capabilities where:
   - The member experience is developed with a mobile-first mindset
   - Everything that can be delivered on-demand to a consumer is on-demand care such as [Asynchronous (secure messaging, chatbots) and Synchronous (tele or video visit)] coupled with on-demand insurance utilization acting almost like a direct health plan.
3. Our current care models are too labor intensive, and productivity as measured by nursing care hours per patient per day has fallen by a factor of 2.3 based on data from 1980 to 2004. Contrast that to other industries, i.e., the automotive industry that adopted automation early on and continues to pioneer the use of robots, visual sensors, and artificial intelligence. Even without the use of modern robotics and computers, Henry Ford increased the production of cars completed per man hour by a factor of 30 from 1913–1927. People are far more complex than cars, but many of the tasks and workflows in healthcare are repetitious but not complex. A focused use of intelligent automation and robotics can make a high order impact to mitigate the labor intensity of the current care model to get the right level of care to where it’s needed most.
4. Quality Care Transparency — Another high potential dimension of healthcare that needs improvement is how we can link the great work doctors do to their compensation through value-based agreements based on outcome metrics. For years, providers have discouraged the adoption of value-based care with an argument that it rationed critical care to patients using medical management guidelines that are too broad and miss the mark.
5. Care personalization — Consumers realize therapeutic approaches are not a one-size-fits all prescription. However, data captured in EMRs is enabling providers to forge more tailored interventions and clinical pathways for their patients that better fit their needs based on their biology, living conditions and other factors. Ultimately, personalized care done well will be a catalyst for increased therapy adherence, tailored to each patients’ particular needs, tastes, and preferences.

Let’s zoom in on this a bit deeper. How do you think we can address the problem of physician shortages?

Video visits are not the answer to mitigate shortages since a physician is merely moving an in-person synchronous, one-on-one encounter to a remote connection. Asynchronous tele-health such as messaging is also insufficient. The provider still needs to dedicate time to responses which can take as much time or more than an in-person encounter. The shortages are not ubiquitous; they are related to disparities in the geographic distribution of doctors in the U.S. Shortages are more prevalent in rural areas and in some metropolitan regions, which have a glut of physician specialties.

Currently, there are over 120 recognized physician specialties in the U.S., and many can make 2– 3x the salary of a primary care physician. This is what incentivizes medical students to bypass internal medicine and family practice. As a result, a rationalization of salaries between primary and specialty care would help to grow the percentage of PCPs thus reducing the probability of unnecessary specialty interventions. It would also be helpful to expand the scope of practice of extenders like PAs and NPs to alleviate the strain. However, while we attempt to expand supply, we can also help doctors work smarter, not harder using analytics driven pre-visit planning, clinical decision support and improved UX with the EMR such as “keyboard less” EMR encounters, driven entirely by voice and NLP documentation.

How do you think we can address the issue of physician diversity?

Telehealth is one area that may be helpful. Even if medical schools admitted 50% males and 50% females, we might still see provider attrition among some of the females who may choose to leave the workforce post maternity. If new mother physicians could practice from home exclusively via synchronous and asynchronous telehealth, a higher percentage of females might remain active physicians for a longer duration of their careers.

How do you think we can address the issue of physician burnout?

We should consider eliminating the present EMR experience entirely from a doctor’s workflow. Let them see pre-fetched and curated medical information as part of their decision-making process. Finally, we should allow them to conduct documentation and make orders via voice commands.

What concrete steps would have to be done to actually manifest all of the changes you mentioned? What can a) individuals, b) corporations, c) communities and d) leaders do to help?

For these changes to manifest, it would require alignment of stakeholders across the healthcare ecosystem including government agencies, payers, providers, associations, unions, and a focused investment in creating standards and building technology infrastructure. However, all the components mentioned are available today and no invention is necessary to make it a reality.

William Gibson said, the future is already here. It’s just not evenly distributed yet”. His words are very pertinent to the healthcare ecosystem. The supply of clinicians, member-centric insurance plans like Sidecar and Oscar, advanced clinical and operations technologies like RPA, NLP and voice recognition exist, but not at the scale necessary to make a significant overall impact.

You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. :-)

Listen2X. In 50 A.D. a former slave named, Epictetus once said, “We have two ears and one mouth so that we can listen twice as much as we speak.” I encourage team members to share and to be patient with one another when they offer differing opinions. Only by embracing the diversity of thought will we discover impactful and lasting solutions. It’s important to set up multiple channels for people to communicate such as text, voice, in-person, remote and even anonymous input. Ultimately, success comes down to being deliberate about inclusion of thought and working twice as hard at listening. Epictetus was right.

How can our readers further follow your work online?

You can follow me on LinkedIn. I post and love to hear comments and feedback.

Thank you so much for these insights! This was very inspirational and we wish you continued success in your great work.