: [00:00:01] Welcome to the Outcomes Rocket podcast where we inspire collaborative thinking, improved outcomes and business success with today’s most successful and inspiring healthcare leaders and influencers. And now your host, Saul Marquez
Saul Marquez: [00:00:18] Outcomes Rocket listeners welcome back once again to the Outcomes Rocket podcast where we chat with the day’s most successful and inspiring health care leaders. I invite you to go to outcomesrocket.health where you could check out today’s interview as well as leave us a rating and review through the subscribe button. Without further ado I want to introduce our outstanding guest. His name is Dr. Iver Juster. He is a very successful leader in health care. He’s got a really great track record of success and he’s done a lot of really interesting things. He’s trained in family medicine practice in Vancouver and also in San Francisco. He really his roots are in primary care. But then from primary care in the frontlines he transitioned to medical management HMO and PPO informatics disease management and outcomes than with the Canadian emr vendor at act of health. He did a lot of really interesting things and then with Aetna where he just applied his his interest in informatics and health economics to take the company to the next level. So that’s a brief introduction on Dr. Juster what you want to do is open up the microphone to him to round that out and add any details that I may have missed. Iver welcome to the podcast.
Iver Juster: [00:01:37] Thanks. Thanks Saul. This is a lot of fun already. You know as far back as I can remember I have never wanted to settle with one thing. I was never like you know how I want to grow up to be a fire man, rocket scientist whatever. I just wanted to grow up to be practically everything nice. I think I was still that way. When I at a college it’s like the St. John’s College in Annapolis Maryland because they offer a truly classical liberal arts education. I mean we were reading Plato and Greek and that went on to major in Philosophy University of Minnesota. And in that process fell in love with science with biochemistry in particular and also from what I observed the possibility of improving health so when I graduated it was natural for me to go into simply medicine and to practice family medicine for many years because I wanted to work with the whole patient even the whole family and eventually the whole system. So at that time the emergence of evidence based healthcare data mining a little bit of artificial intelligence that’s been a longer journey. And I think its founders realized it was going to be but joined to HMO that was FHP a staff model HMO that was trained a lot of medical directors and clinicians. Some startups and asked to help when it was a startup that’s a clinical decision support company who it was later bought by a Moneta. Now this passion again for silo bridging is the guy like. Or just bring in somebody who can talk to everybody and I really like that I really loved seeing those points of view and trying to incorporate them in whatever product or process we were doing. I’ve really been blessed with a variety of different kinds of mentors in on the job training. Over that time so hard to pin down I guess I think that that might be an advantage in some in some areas.
Saul Marquez: [00:03:27] Well you’re you’re a Renaissance man Iver and from the classics that you read in college to your varied interests in healthcare and beyond. You definitely have a very unique perspective to offer in that thought what would you say. Every medical leader today needs to be focused on.
Iver Juster: [00:03:47] You got to be thinking about what is the current big thing. So we talk about the next big thing and it’s only next if youre not aware of it. And I would now say be aware of some of these trends that are occurring right under our noses and hopefully weve got a good sense of smell to smell them because they in many ways seem far away or not terribly relevant. Name a few of them. Be aware of what’s going on for example in genomics microbiomes that the OMEX as they’re called are so many of them. Be aware of what’s going on with the advent of gene sequencing. Anybody can get there 23 And Me for example which is most relevant parts of your genes done for under 100 bucks. Probably you’ll get your whole genome sequenced for nearly that price in five years. It’s what’s going to happen when everybody can get that and they’re going to their doctors with her what am I supposed to do with us. Hopefully their doctors will be coming to them and that’s one of my missions in life I guess artificial intelligence and machine learning nanotechnology the ability to sniff out prevent and fix disease at a molecular level. Yeah this stuff is new. It’s emerging. But if you’re not aware of it it’s going to creep up on x some of the other things have in other areas besides business that’s today. What’s over that horizon that maybe not so very far is when all these things really begin to interact. That intersection of technology the ability to collaborate across the globe instantly the availability of information by the way it’s good information bad information. I don’t know what to do with this kind of information. Are we going to help our patients and our constituents to sort out what’s good information what’s bad information out of sync. Because that’s what they’re coming in. And one of my motivating force is missing family members and close friends and sometimes going into the doctor with them so we can also have a doctor to doctor talk and seeing that there just needs to be a world more of curiosity a world more of curiosity and you know I also relate to having to see a patient every 15 months and half of that’s probably dealing with the EMR and insurance companies and how are we going to solve that problem so that people can get the benefits from healthcare that they’re really that they’re yearning for.
Saul Marquez: [00:05:57] Iver you dove into a lot of different topics and for the leaders listening to to this private eye whoa that is a firehose of things. And the reality is that’s health care for us today. And I love that you mentioned this thought that not today’s big thing everybody always talks about the next biggest thing but what is today’s biggest things and what are you and your organization doing to dive into those at the end of the day. You really can’t dive into all of them. What areas are you going to choose to make moves on. That’s going to create a compelling future like the Gretz ymax Zimride.
Iver Juster: [00:06:38] Yeah. And having worked on a Canadian company that was one of our favorite mess that was one of our favorites. We then we looked at that we said and this was back in about 2000 when we didn’t have anything like the information technology and connectivity we do now but we had to be thinking Yeah but what’s this going to look like in five or 10 years. But let’s say for example and I think it depends on who you are. But let’s say you’re multi-way specialty group practice can easily relate to that glossary. Patients are starting to come in with stuff they’re reading on the Internet or they’re learning on Facebook. And I think for truly every disease now has at least one Facebook page and patients are talking with each other and some of them love their doctors some of their doctors. I hope doctors will start reading some of these Facebook pages just to lurk and see what their patients are really thinking because otherwise the patients will just go somewhere else eventually. I remember when I was seeing patients in one of the surest clues that the patient didn’t have any idea what I was talking about as if I asked them to understand and it’s a. It’s also the body language. Well those days are coming to a close. And so put yourself in your patient shoes and if you’re not a patient much of a patient yourself you only go in because you’re healthy or you go to a small thing then go in with somebody who isn’t healthy and just learn what it’s like to be in their shoes. So I think that that’s learned what it’s like to be in their shoes is probably a good model for leaders in any industry.
Saul Marquez: [00:08:01] I think that’s a great example. However the other day Well a couple of weeks ago I got the flu and just feeling so sick. And while the flu is just the temporary thing that goes away the intensity of it for the two days that I had it was just rough and it made me feel that I think that what you’re going after is that compassion. Right. Like having compassion for the person in that room that needs your help so much.
Iver Juster: [00:08:25] Absolutely. You know I think people like to have three Cs for things sung to do compassion caring and curiosity right here because it was important that the doctor realized that maybe what you had wasn’t the flu. And without taking a 15 minute pointman turning into an hour to just like to realize that you were in a sad enough state to want to go wait in that waiting room and sit around and find out what was going on. And it’s hard to when we’re rushing around. It’s hard to put ourselves in the other’s shoes. It’s we got to force ourselves to do it. And it’s so rewarding when we do either. That’s true in organizations too. You’re in a meeting and somebody has a point of view and I have a point of view and somebody else has a point of view. And everybody has a point of view they have. Right. If I would I would like that other person or department to say as I would like to. What’s it like to be you. What do you wish I knew about you. And I would say the same thing to them and let me progress a lot faster not only with her patients but in organizations.
Saul Marquez: [00:09:28] I think that’s a great call out. And as you think through the different things that you’ve done in your career as a as a health care leader Iver what would you say one of the things that stands out as maybe a setback that you had that you learned most about.
Iver Juster: [00:09:44] This goes back to my early days of when I transitioned to medical management in the age of Oh. And they asked me to get together a group to set up a pain clinic. So clinics are inherently multi specialties they’re very often run by anesthesiologists. Now it is pain management is more of a specialty that can be run by a pain management specialist anesthesiologists in those days. So I quickly met the very delightful head anesthesiologist at the hospital that was closest to me that this organization owned and we busily started getting the team together and setting up the good that about a week later I get a call from the other industries theologist the head of anesthesiology at the other hospital who was kind of miffed. But you know how come you didn’t like me at my hospital. And I actually don’t know why I didn’t think of him in his hospital. I just didn’t. And what I learned from that and we became good friends and very good colleagues and actually did set up a dynamite Pain Clinic for the HMO. But what I learned from that is what I don’t know. It’s one thing to you know like I know that what I don’t know I don’t know how to fly an airplane. What about the stuff that I don’t even know that I don’t know. And there was a real good example of that. How do I get it that other people might know it or at least my clue me into it. And so it’s got started to that curiosity thing has started asking questions like well what am I missing here. What could I be missing here.
Saul Marquez: [00:11:04] Yeah and asking the question and also surrounding yourself with other people that you could potentially get feedback from. Right.
Iver Juster: [00:11:11] Yeah. And actually listening to it.
Saul Marquez: [00:11:13] Yeah I definitely definitely see what you’re saying. I think of my financial adviser for instance you know I see something I want to run it by him and we talk it through and oftentimes he’ll see some blind spots that I had and an idea and why not do this in every area of our life including health care.
Iver Juster: [00:11:33] Absolutely. The urge to protect is so biologically where it ends and usually so you know 95 percent of the time maybe that’s great. The other 5 percent though and in a rapidly changing world the back to this exponential thing in this rapidly changing soon to be disrupted world that 5 percent suddenly grows to maybe 50 percent. And even organizations even are. It’s said the death or even organizations have an immune system like the body does. And now that’s you know I don’t see that that’s good. I don’t see that that’s valuable. And on top of that kind of threatened. So it’s better more than play nice. We have to play creatively and I think we’ll have more fun doing it. But it takes a change in mindset.
Saul Marquez: [00:12:11] What would you say Ivor is one of the proudest medical leadership moments you have experienced to date.
Iver Juster: [00:12:17] Joined an organization called the disease management association of America DMA back when it formed. It’s got to be at least 15 years ago. And a few years later now it’s population health alliance. A few years later we convened consultants actuaries medical directors and people who have to implement stuff. And I think nowadays would probably include a few patients to produce books. And this became an annual thing on guidelines for how you measure outcomes. So how do you determine what outcomes to measure how do you measure them how do you avoid the bias so that you’re actually measuring the outcome and not the bias of those sorts of things. So a series of those I think some of them are still available on the population health alliance website and we can put that in the shownotes. Then a few years after that the Population Health Alliance joined was the hero organization that’s the Health Enhancement research organization which principally serves employers and their employee health programs. And we produced a magnum opus that took about two years many teams and I loved the financial outcomes section and the process of getting that together and leading that section because measuring financial outcomes of a program that’s very different if you have diabetes it’s one thing if you don’t but you’re at high risk it’s another there’s lots of moving pieces. Doing that is still highly contentious and people from companies who were in direct competition with each other had to be brought together and have a good time producing this thing and say no we’re our secret sauce needs to be how we improve outcomes not how we measure them. We need to measure them the same way and so that that was a proud moment when we launched the first edition back in 2015 and again I think we can probably provide a link in the show notes it’s a free download.
Saul Marquez: [00:13:58] Beautiful. Yeah thank you for sharing that resource and congratulations on that accomplishment and times we need to reach across the aisle and work with those that are potentially our competitors to figure out a way to get to the next level as a whole.
Iver Juster: [00:14:13] Agreed.
Saul Marquez: [00:14:14] Ivor what would you say. Right now an exciting project our focus that you’re working on.
Iver Juster: [00:14:20] You know I’ve been taking a lot of courses and conferences the last year as it goes practically working on almost reeducating myself in those OMICS that we’ve talked about the G.L. mix a microbiomes mix. There’s probably about 10 different mix and in fact like to call out Eric Tocqueville’s great paper in the journal Cell which again I could give her and that’s a free download here classic on how the mix worked together. So I think diving into these kinds of relationships but the thing that’s turning me on and getting me out of bed in the morning more than anything is how do we get that to doctors and patients and with my primary care background of most interested in getting it to primary care docs and their patients empowering them. You know I live in a place in Northern California where just about everybody has had at least a 23 and Me done if not their entire genome sequenced. Then they bring it to me like I really don’t know how I got this badge or my space with this thing. OK. And then they bring it to their doctor who of course hasn’t taken several hundred hours of these genomics courses like I have. And yet there it is. And it’s kind of stupefying people. And what do we know what don’t we know and how do you keep up with that in that doctor patient world. I think that’s the most exciting thing I’m doing right now. I’m working with some companies to do analytics and make sure people understand the nuances of methodology. So again you’re measuring the outcome not the method you use to measure the outcome. And that’s also very exciting because you see people’s faces light up so kind of twin projects there.
Saul Marquez: [00:15:53] I love it. And I can definitely hear the excitement in your voice when you talk about it so exciting to hear you diving into these things. So Iver let’s pretend you and I are building a medical leadership course on what it takes to be successful in medicine today. It’s a one to one or the ABCs of Dr Juster so we’re going try out a syllabus. I’ve got four questions for you that our lightning round style and then we’ll finish up with a book. You ready.
Iver Juster: [00:16:20] OK.
Saul Marquez: [00:16:21] Alright. What’s the best way to improve healthcare outcomes.
Iver Juster: [00:16:25] Am going to name three things but they’re totally related do it first specify your stakeholders. That is the people or the institutions that care about what you’re doing about your world and define what value is from these key perspectives. It’s valuable to them. You know don’t make it go find out give feedback and then set up a news and outcomes monitoring system. Those metrics then and this is the critical ones actually use the systems that you set up and be ready to actively improve. And then third is prepared to be disrupted or be a disrupter and you can’t disrupt everything but you could be disrupted by everything and by these exponential advances that sharply improve the cost per outcome value relationship. So few invested in ten million dollar person genome sequence or ten years ago I got news for you there are like well under a thousand now and so at least be curious about what might be disrupting me. So I think those are three related topics having to do with outcomes.
Saul Marquez: [00:17:22] Yeah. Iver. I love the. You said you know don’t just guess define your stakeholders and ask them what value is to them. Do not guess measure clearly and use the systems to measure clearly. And I think that’s a really great call out that youth is prepared to be disrupted. This is sort of coming from the seat of somebody that’s seen all the things listeners so take into consideration and this pathway that Iver has laid out for us it’s a really really crucial one. What would you say Ivor is the biggest mistake or pitfall to avoid.
Iver Juster: [00:17:56] Well I’d say not being alert and curious and not putting yourself in the other person’s shoes so I’ll take a nonmedical example from last week hosting at a Marriott hotel and I’ll of Maria. But you know most of the people it’s that these kinds of hotels in the middle of a city are working. Yes. And so they might go home late and you know do some e-mails at night or whatever and the desk chair goes I think you’d get if you’re at least six foot six you’d be OK. If the tallest you could make that thing was way too low. And I’m thinking that these people actually use their rooms like they should go stay at the Marriott for a few days and try to work. Yeah. And so this is and this is not a slam against Marriott. I love that chain but it’s back to that put yourself in your customers shoes and your customer Chris could be your patient choices or somebody else on your team. Don’t fall too much in love with your own ideas.
Saul Marquez: [00:18:46] I love it. How do you stay relevant as an organization. Despite constant change.
Iver Juster: [00:18:51] You know I think that companies need to invest in the ongoing education in their talent. At every level and look outside your domain I can remember who it was who said most of the smart people don’t work for your company even if you’re Google. I think I was probably somebody from Google or Apple who said that go to a futurist meeting or sit down with a thoughtful futurist just a list that these other points of view. And when you can start being up on your ideas and say How are we going to improve this or is it good enough. You’ll have the metrics to end the curiosity to do that.
Saul Marquez: [00:19:21] What’s one area of focus that should drive everything else in your organization.
Iver Juster: [00:19:26] Make sure the data and methods you’re using to measure your performance are to improve your performance aren’t more about the methodology that is the bias. I’ll give you an example just the second the bias the noise the luck. You know something’s just happened by luck. That’s the history of medical science is littered without know the first study comes out get wow look at that effect but five years later and usually on the back page it was like three more study. Really it’s only like a 1 percent improvement instead of a 30 percent. Now you got to look at that kind of stuff and bias comes in many flavors even in randomized studies. People say well we did this randomised controlled study and we showed that this was drug was 30 percent better than that drug. Well maybe it was or maybe it has something to do with the bias of people who sign up to be randomized in a drug study. So we got to look at that sort of thing because there are about those driving forces for and also things that improved outcomes 20 years ago might not work now. Classic example beta blockers after a heart attack. There’s some 20 years ago there were protests 30 years ago. Take us practically a miracle drug we still use them they’re still valuable. But since that time there are so many other things that prove it comes after a heart attack. The original effect size will call it of the beta blockers isn’t quite as much.
Saul Marquez: [00:20:40] This is good to be good and you know listeners as you dive into this thought process. You’ll notice that Iver takes a very critical look at how we place bias as part of our decision making and making sure that when we measure we don’t measure the that method gathering data but we’re measuring the actual outcomes and being less biased about it. This is a really great message.
Iver Juster: [00:21:07] Yeah and if you don’t know which one you’re looking at look friendly neighborhood biostatistician or somebody who’s thoughtful but somewhat skeptical. So you know you see like is there something where the results I’m seeing could be the result of the way of measuring it not of the thing itself fiver.
Saul Marquez: [00:21:22] How do you find your neighborhood biostatistician Because
Iver Juster: [00:21:24] I don’t know they are friendly. If you’re in a large enough company I’m sure you have one but are sure if. And certainly there’s consoles that hurt themselves. Maybe I’ll read a paper about it actually though if you look at the population health alliance Acurio guide measurement that will reference the notes. There’s a fair amount of that kind of stuff there they’re.
Saul Marquez: [00:21:47] Beautiful I love it. I love it so they have it listeners what book would you recommend. Iver.
Iver Juster: [00:21:53] Can I give a tie for first place.
Saul Marquez: [00:21:55] That’s fine.
Iver Juster: [00:21:56] Okay. The first one I’d recommend is a pundit’s. The future is better than you think. By Peter Diamandis positioned himself as an entrepreneur and the second would be the patient will see you know by Eric Topel. These two guys changed my life.
Saul Marquez: [00:22:13] Outstandings so listeners check those recommendations out go to outcomesrocket.health/iver that’s I V as in Victor e r Iver and you’ll be able to find a link to those books. All the resources that he just mentioned as well as the show notes ever. This has been a lot of fun. But before we conclude I would love if you could just share a closing thought and then the best way that the listeners could get in touch with you.
Iver Juster: [00:22:39] Wake up every morning to the vast potential of the day to inspire awe delight and wonder and the potential of human connections especially ones that you know the surprise factor that will be the delightful surprise factor of course. And think you know if you wake up on another day think OK what about all wonder and delight because then you can create a world that really incorporates your best your personal and unique visions. So in my case you can produce lots more outcomes that way less cost. You know that’s a good one but whatever that is for you put on your mirrors after this. Get in touch. Best through Twitter. @iverjuster or LinkedIn would be a Iver Juster, MD good places.
Saul Marquez: [00:23:24] Outstanding. Great message to close off with Iver and again just listeners feel free to follow Iver in the resources that he suggested and through Twitter and LinkedIn. He’s putting out some really good ideas out there in the form of articles and just participation in the different forums so I just want to say thank you so much and looking forward to stand and touch.
Iver Juster: [00:23:47] Great. Thanks.
: [00:23:52] Thanks for listening to the Outcomes Rocket podcast. Be sure to visit us on the web at www.outcomesrocket.health for the show notes, resources, inspiration and so much more.