Dr.William Flood: “Be flexible in problem solving”

I’ve used the current “work from home” model as an opportunity to address my fitness. I’m a poster child for what happens when one sits too much — bad posture, less strength, less flexibility. I certainly hope that has dividends for all parts of my life and I think many Americans can greatly benefit from incorporating more […]

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I’ve used the current “work from home” model as an opportunity to address my fitness. I’m a poster child for what happens when one sits too much — bad posture, less strength, less flexibility. I certainly hope that has dividends for all parts of my life and I think many Americans can greatly benefit from incorporating more exercise into their lives as well.

I had the pleasure of interviewing Dr.William Flood the Chief Medical Officer for Eviti at NantHealth, a next-generation, evidence-based, personalized healthcare company enabling improved patient outcomes and more effective treatment decisions for critical illnesses. Prior to his role within NantHealth, Dr. Flood has served as Assistant in Oncology at the Johns Hopkins Oncology Center, Assistant Professor and Associate Professor of Medicine at the Penn State College of Medicine. He is a multi-time graduate of Penn State (with a bachelor’s of science in molecular and cell biology and a master’s in health evaluation sciences) and earned his medical degree from the Temple University School of Medicine. He performed his post-graduate medical training at the Duke University Medical Center and the Johns Hopkins Oncology Center. While in active clinical practice, Dr. Flood was named a “Best Doctor in America” for many years.

Thank you so much for doing this with us! Can you tell us a story about what brought you to this specific career path?

Serendipity. I was able to formally study various aspects of assessing quality in medicine -biostatistics, epidemiology, trail design, health economics — early in my oncology career. Knowing my background, one of my fellowship mentors reached out to me about an opportunity at a start-up company, ITA Partners, whose goals were improving quality in cancer care and encouraging clinical trial enrollment. This opportunity dovetailed nicely with my oncology training, this extra study, and my excitement about the concept of value-based medicine; I had just finished reading Roger Lowenstein’s article “The Quality Cure?” in the New York Times Magazine. And to top it off, the CEO was a man I had met a few years earlier at a cancer research meeting; we sat next to each other at the bar of a great seafood restaurant because the tables were full.

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

I am not the leader of my company, but one of many who have been able to contribute to its growth. The excitement started on day 1 at ITA Partners, the case management precursor to Eviti within NantHealth. The highlight of that day was a teleconference with a potential client, the HR lead for a large Gulf State university. We talked about improving the patient experience — price transparency, shared decision-making, provider scorecards — not simply saving money. A few weeks later, we were on-site at that university, finishing up our implementation. A few weeks after that, we were helping those university employees with cancer continue their care all across the US, after they were dispersed by Hurricane Katrina.

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?

There have been a lot of entertaining and humorous events, probably because of the quality of people in the company. One recurrent theme has been the wide variety of people we have encountered. Not sure it’s funny, but I’ll never forget an executive meeting that was interrupted by a call from the Treasury Secretary (Mr. Paulson was certainly NOT calling for me!). My takeaway from these encounters is that our goals and products can have a profound positive effect on everyone

What do you think makes your company stand out? Can you share a story?

I like a lot of things about our company, such as our commitment to transparency and data integrity for example. But one thing that really stands out has been the long tenure of most of our employees. In my 15 years here, we have only had 2 or 3 people leave our content team. I think that’s a reflection of both identifying the right people through good hiring and training, as well as having a culture that keeps everyone engaged and growing. Fortunately, that tenure has not led to delays in continuous improvement, as our team members look for and readily adopt better ways of doing things all the time. To steal from Jim Collins, we have the right people on the bus, and they don’t mind changing seats or vehicles.

What advice would you give to other healthcare leaders to help their team to thrive?

Be flexible in problem solving. There’s a story from Desert Storm where a Saudi general called the US Air Force for a B-52 strike on a city that had been captured by the Iraqis, at which time General Horner, the coalition air commander said something like “Tell me your problem, and I’ll tell you the solution.” A B-52 strike would have laid waste to the city, but the package sent by General Horner selectively targeted the invading force, allowing recapture of the city with less loss of life and property. We’ve had examples — internally and externally — where the expected or requested solution did not address the real need or was not the best solution for that need. It’s great when you know your team can identify effective, out-of-the box ways to solve problems!

Ok, thank you for that. Let’s jump to the main focus of our interview. According to this study cited by Newsweek, the US healthcare system is ranked as the worst among high income nations. This seems shocking. Can you share with us 3–5 reasons why you think the US is ranked so poorly?

I don’t think my observations are novel, but here they are:

1) Lack of alignment: There are many layers to every part of the health care “system,” and the scorecards, incentive and disincentives frequently don’t line up or can actively conflict with each other. A simple example could be that a hospital wants to discharge patients as early as possible to allow for incoming patients, but individual providers have other responsibilities that may not allow hospital discharge to be her/his priority: busy office schedule, maybe a procedure schedule, and/or other necessary activities. To me, this is a “simple” example as the goals and incentives for each stakeholder aren’t contradictory, they just led to different priorities for each. There are many more areas across the health care spectrum where the goals and incentives are more antagonistic. Better alignment across stakeholders is a goal of value-based care.
2) The term health care “system” can be an oxymoron: The word “system” implies that an overall process has been designed for logic, efficiency and with the same goals. But that is not the case with health care; our “system” emerged over years of pushing, pulling and the entry of new stakeholders into health care. This leads to 2a) we may have best medical science and technology in the world, but we don’t deliver that science and technology effectively.
3) Information asymmetry in health care: The overwhelming amount of information in medicine challenges a provider to remain up to date on standards of care and emerging data while also completing all the other tasks necessary to deliver care that already take up 120% of their 100% day. Now add on things like costs, appropriate use of new technologies, insurance policies, pharmacy policies, patient copays, and many, many more. And that is just from the provider point of view; how can a patient/family make truly informed decisions on all of these issues, especially when much of that data is not readily available to them?

How can a payer keep up with the weekly and monthly avalanche of new knowledge?

This is an area where NantHealth’s Eviti platform makes a real-time contribution as a clearinghouse for up-to-date information, facilitating quality care in cancer. For the provider and payer, Eviti Connect collects patient information and proposed treatment data and compares them against our comprehensive cancer library in real time, allowing faster delivery of quality care. For the provider, Eviti Advisor presents this library so the provider can review many treatment options that fit the patient, based on that patient’s individual characteristics. Data such as effectiveness, side effects, study quality, and costs is available not just for provider decision-making but also for shared decision-making discussions between the patient and provider. We are looking forward to applying the technology and skills honed in cancer to a variety of other medical conditions.

You are a “healthcare insider”. If you had the power to make a change, 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) Align incentives, as above
  • 2) Simplify and make transparent the flow of money in health care. I’ve been a practicing physician and/or CMO for 20 plus years, but I am still frequently surprised by the flow of money across the stakeholders. I mention this example NOT to highlight or pick on one particular group of stakeholders, but because it was recent. During his talk at the 2019 Association for Value-Based Cancer Care Summit — a great meeting for those with interest! –
    Bruce S. Pyenson, FSA, MAAA, of Milliman illustrated potential cash flows and tax treatments of monies between patients, providers, payers, pharmacy benefit managers/specialty pharmacies, and pharmaceutical companies around the use of certain drugs. I left there both educated on these flows that I did not know before, as well as uncertain how all these shifts led to savings to the patient or employer — the real purchasers of health care. Again, I’m sure there are many examples of opportunities for increased transparency across any combination of health care stakeholders.
  • 3) Increase teamwork and collegiality across health care stakeholders. When in full-time practice, I was inconvenienced by paperwork or phone calls from payers regarding a patient’s plan of care; “I completed medical school, residency and a fellowship, I know what I’m doing.” But by assuming my current role, I was introduced to the breadth of stakeholders in in our system, each with a role to play. When everyone is busy doing their usual job, it can be hard to take that time and collaborate with others in the system outside of your usual workflow, but it’s just as important to assuring quality care for a patient as doing a good history and physical.
  • 4) Increase connectivity and functionality of electronic medical records (EMR). I left full-time practice just as my site of practice was adding computerized order entry to our EMR, so I’ve been spared much of the inconvenience encountered since by my colleagues. But there are a lot of data points illustrating that EMR’s are not making medical care easier or more effective: many practices hire scribes to record the provider/patient encounter; communication across platforms systems is not easy — medicine is one of the few industries where the fax machine remains invaluable; reporting quality metrics or other metadata within or across patients remains difficult, adding new functionality or outside software can be problematic and the like. EMR’s collect data but still don’t help providers enough to make sense of or use the data to practice more effectively. Paraphrasing a former NantHealth colleague — a pilot as well as physician: “In any plane, you have a maintenance record under the seat to keep track of oil changes, overhauls…If you have a really expensive plane, you have a maintenance record and an autopilot. EMRs are still too much maintenance records and not enough autopilot.” One of the real challenges here is that these systems can be so expensive and purchased as enterprise solutions that create scale for an overall enterprise, but don’t really empower individual providers or specialties of care well.

Ok, its very nice to suggest changes, but what concrete steps would have to be done to actually manifest these changes? What can a) individuals, b) corporations, c) communities and d) leaders do to help?

Members of each of the four categories can have different opportunities based on their role at any given time. For example, an individual may be a patient, a family member, a provider, an employer. A corporation can be an employer paying for health care, part of the health care industry, or both. Here are some general thoughts about my four changes and the four groups. Warning — do not underestimate the inertia in making change!

a) Individuals have a huge challenge in changing parts of the health care system as they are individuals and they have full time roles elsewhere: patient/family member/friend, parent/child, employer/employee, provider. But they need to be their own advocates in such a complex system too. The non-provider should expect more information about any specific medical issues from trustworthy sources; don’t be afraid to ask for second opinions, pricing of treatment options, or asking about lower cost ways to get the same care; push your insurer to provide as much support as possible, not just care reimbursement, but case management, pharmacy support and the like; check with your employer (if your coverage in employer-sponsored) for availability of services from relevant departments. The provider or small group can employ standards relevant to that specialty that can be easily recorded and reported; report them to major payers, employers in area to demonstrate value and improve referrals and/or reimbursement; expect your institution to improve EMR functionality to improve your effectiveness in providing care, address the needs of your specialty, provide quality reporting for your own QA/QI but also more effective reporting to payers to drive better reimbursement when warranted; collaborate with your payers on day to day interactions as well as opportunities to shape policies, better reimbursement models.
b) Corporations and leaders — As the majority of health care coverage in the US is employer-based, employers can effect change through both their own purchase decisions, but also by uniting with other employers and purchasers to make better purchase decisions or to ask for broader change — the LeapFrog Group is a great example of the latter. Expect coverage that is empowering quality, transparency, and quality-driven reimbursement, with a clear understanding of how savings obtained by the payer’s interaction with other stakeholders are reflected in savings to your premiums and member’s costs; assist employees in accessing payer services beyond reimbursement, outside services when needed. I believe a LeapFrog-like approach from the real purchasers of health care demanding more productivity from EMR’s would be helpful (and may already be underway). Consistent demand for transparency and value by health care purchasers will be the most important tool to overcome inertia in the system.

c) Communities — As my experience has been in the industry rather than from outside, I don’t think I can give good advice to communities on execution. However, I do know how vital community efforts — whatever definition — are to change. LeapFrog is an example of a community effort, in this case a community of employers and purchasers. My favorite example — reimbursement of routine care as part of clinical trials in 2000 — came about by the collaboration and efforts of many different communities: patient advocacy groups, medical professional groups, scientific group, pharma, for example.

I’m interested in the interplay between the general healthcare system and the mental health system. Right now, we have two parallel tracks, mental/behavioral health and general health. What are your thoughts about this status quo? What would you suggest to improve this?

I’m not an authority, but I think your question hints at the issue, why are there parallel groups? I am aware of efforts to breakdown this separation of the two, from Tipper Gore’s work in the ‘90’s to periodic efforts in Congress since. I’m sure that there are groups trying to break through this separation, but likely made difficult by inertia and a smaller number of communities that focus on mental health over other aspects of the health care system.

How would you define an “excellent healthcare provider”?

There are so many traits and skills involved in health care delivery, a default could be a health care version of the Boy Scout Law: a healthcare provider is trustworthy, brilliant, informed, compassionate…. But for simplicity, I’d rather steal from Sir William Osler, the incomparable physician educator from the turn of the 19th and 20th centuries. In his valedictory address at the University of Pennsylvania, he proposed that equanimity is the most important trait in a physician. While I don’t think Osler imagined the complex web of our current health care system in 1889, I think his advice is still on-target for anyone across the spectrum of health care, from the front line provider to someone working in a payer back office. All have roles in the team delivering that final product to the patient.

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

Hard to say I have a favorite or one that has been most impactful, as just when you think you have found the perfect one, Google may you show you another! I think one I want to be more mindful of is “It’s not about you.” Whether in the context of faith, family, country, job, service, it simply works. Osler’s Aequanimitas fits here too. I have to keep both in the front of mind better.

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

Within our company, I am excited about some development of new products regarding non-oncology specialties, new ways to deliver our information to broader audiences, and improvement in some of our internal processes for both increased scale and productivity. Our current services clearly provide value in our market through increased transparency and quality, so expanding our services and our market will bring these benefits to a broader audience.

I’ve used the current “work from home” model as an opportunity to address my fitness. I’m a poster child for what happens when one sits too much — bad posture, less strength, less flexibility. I certainly hope that has dividends for all parts of my life and I think many Americans can greatly benefit from incorporating more exercise into their lives as well.

What are your favorite books, podcasts, or resources that inspire you to be a better healthcare leader? Can you explain why you like them?

Here are some recent finds I find valuable:

1) Jocko Willink is a retired Navy Seal now doing leadership coaching. A NantHealth colleague sent a link to one of his podcasts to me. I subsequently read and greatly enjoyed his book “Extreme Ownership: How U.S. Navy SEALs Lead and Win.” When commuting, I would listen to his podcasts regularly, but now I am picking and choosing topics from his large library.
2) Success Mindset for Physician Leaders and Entrepreneurs is a program by Dr. Elsie Koh. She has a compelling personal story in leadership development that led her to start these interviews with current physician leaders. I believe the stories she present fits a theme from above of going from the individual physician to the physician leader, then medical corporation or medical community leading change.

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. 🙂

As I said above, my picture from a few months ago could be next to “the Sitting Disease”: upper cross syndrome, lower cross syndrome, bad cardio, overweight. Thankfully, I have been able to address this recently. After pursuing these goals through research and exercise, I have a more acute appreciation of the potential impact of good exercise habits on the individual and the subsequent downstream effects for our society. There are many resources available, but the issue is in identifying ways to effectively educate and generate consistent exercise when all of us have other daily challenges, not made any easier for young to old by the ongoing pandemic.

How can our readers follow you online?

Readers can follow me via my LinkedIn page and through the NantHealth blog and webinars.

Thanks for this opportunity!

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