Ep 13: Next-Generation Innovations in Healthcare with HSS CTO Bashir Agboola

Saam Motamedi: Hi there and welcome to Enterprise Software Innovators, a show where top technology executives share how they innovate at scale. In each episode, enterprise CIOs share how they've applied exciting new technologies and what they've learned along the way. I'm Saam Motamedi, a general partner at Greylock Partners.

Evan Reiser: I'm Evan Reiser, the CEO and founder of Abnormal Security. Today in the show, we're bringing you a conversation with Bashir Agboola, Chief Technology Officer at Hospital for Special Surgery. HSS is one of the world's preeminent medical institutions that specialize in orthopedics and providing care to patients from over a hundred different countries. In this conversation, Bashir shares his unique perspective on digital transformation, next generation technologies deployed to HSS, and upcoming innovations in the healthcare industry.

Maybe just to kick it off, do you want to share a little bit about, just background and your role at HSS?

Bashir Agboola: Okay. I grew up in Nigeria. I came to the States in the late '90s. My primary education and my beginning of my professional career started in Nigeria where I started computer science at the bachelor's and master's level. I had the opportunity to immigrate to the US in the late '90s when an IT services company in New Jersey hired me. I came in, did some work with them consulting with their clients and that journey led me into healthcare at Memorial Sloan Kettering Cancer Center, where I worked initially as a consultant for my employer, and then I joined the MSKCC top tier, top ranked cancer care institute, I joined their team as a full-time member.

I'd like to say that I grew up there because I learned so much there. Went on to business school while I was there, rose through the ranks from an individual contributor role to management. I was there for several years until the opportunity at HSS came up. When HSS was embarking on a major transformation, this was about eight years ago, the institution recognized the need to reshape itself and to transform, not just from a digital transformation perspective, but really on multiple levels.

One of the changes that they had was in the technology organization. A new team was put together. I got the job, came on board as a CTO, embarked on a massive infrastructure transformation process. At the same time, the institution put in a new EHR. It was a new beginning for an institution that's over 150 years old. I've been there since with the oversight of the infrastructure and operations function at HSS as a CTO.

At MSK that I mentioned earlier, again, it's similar function, but on a smaller scope. Before then, in my consulting role, I did the typical generalist IT systems person. I did Unix, Linux, Windows, the fun stuff, and I really enjoyed it because I like tinkering, I like fixing stuff, and creating solutions. That's been the CliffsNotes about my professional journey.

Evan: That's awesome. Well, you're among friends. I think Saam and I are both builders and fixers and get a lot of joy out of using technology to build things. Saam, let me turn over to you.

Saam: I think just a plus one to what Evan said, one of the reasons we've been excited to have you on, Bashir, is also healthcare as an industry is going through such an important transformation using technology. I think there'll be interesting stories and insights you can share around what's happening from the HSS perspective. In your introduction, you mentioned the digital transformation HSS that's going through. I want to double-click on that. Maybe just to start, I'm curious to how you define digital transformation?

Bashir: The model that I like to use for digital transformation is a three-dimensional model. That model calls for a focus on your products and services, what you sell, and then the second dimension to that is the channel through which you engage with your customers, how you sell to them. A third dimension, which is often neglected by even some organizations that you would think are at the forefront of technology, that third dimension is the operations itself.

Prior to the pandemic when our organization was talking about digital transformation, unlike most other healthcare institution, our focus was really on the channel of engagement with our customers, the omnichannel. Everybody has seen what happens in retail and how consumers have gotten used to engaging with retail companies with ease or retail banking. Healthcare wanted to replicate a similar experience. Everybody had an omnichannel strategy in place, we're implementing at different levels.

To me, a true digital transformation effort must take care of those three dimensions. It took the pandemic to get many organizations to recognize the need for that third piece, which we can call the digital workplace strategy as a sub-component of an overall digital transformation strategy. The digital workplace is how you think about enabling your internal operations. How do you do what you do within your organization? Some folks, some companies had to scramble to send people home when the pandemic broke because they weren't set up to work remotely. They had paper-bound processes, they had workflows that required someone to still be present in the office, even if other members were remote because there are steps or tasks that someone still had to do physically.

Of course, in the last two-and-a-half years, many organizations have, as I like to describe, digitally reinvented many of those processes. They've done the process re-engineering. That was a big deal many years ago. We talked about process re-engineering 15 years ago. Now people had to do that in light of what the pandemic uncovered, that unless you included your operations in your digital transformation, you're going to leave an important component of what you-- For me, digital transformation is taking care of those three aspects of your business.

Evan: We've heard from other guests that COVID-19 was, especially in older organizations, a bit of a forcing function to accelerate digital transformation. Can you maybe share a little bit about how COVID has changed the technology landscape or how it's affected the organization or how it's affected digital transformation?

Bashir: Yes. We went from an organization where, as at 2019, probably had less than 1% of our workforce working remotely to, within two months, by March of 2020, a third of the organization was working from home. We had to enable that technology. To me, and I'm sure to other infrastructure and operations leaders in healthcare, it was finally, "Yes, this is what we've been saying all along. We need to focus on digital workplace transformation. It's part of any digital transformation effort."

It finally sunk in when folks started saying, "You know what? It's digital transformation." Of course it is. Go back to late-- as at 2019, end of the year 2019, in that entire year we had less than 1,500 telehealth sessions. 12 months later we had over 123,000 telehealth sessions. Much larger organizations than us would probably give you bigger numbers, but probably similar percentage growth.

That was just a huge one and it upended many of the objections people thought existed about embracing telehealth, "Okay--" objections about maybe, perhaps clinicians would not want it, clinicians wanted to touch their patients and all of that. When we had to do it, we did it and people embraced it. That's helped a great deal and that's really focused us also and many, many others.

We launched our digital front door during the pandemic. Of course, the plans predated the pandemic and we have a digital app there. We're minutes to be the go-to resource for anyone out there who needs information on musculoskeletal care. Whether you want to come to HSS for care or not, we want our digital front door to be your number one go-to resource for information, anything musculoskeletal care. If you then choose to engage with us, you'll be able to do so from that same app. That's our digital front door, MyHSS app. It's in the major app stores.

We're building other products. We have a digital team. In the last four years, we've built a robust, sophisticated digital team. We've built a very strong data analytics team, doing some groundbreaking work in terms of data analytics. We really leapfrogged from where we were maybe five years ago. We probably would consider, like, that ourselves in that space. We've really gone much, perhaps higher than many other top tier institutions in that space.

Evan: It sounds like COVID-19 was a catalyst. You said you had this plan on the shelf and all of a sudden you're able to pull it really quickly. Some of the data you shared was just emblematic of what a big transformation it was. Have you seen that propagate forward? Has that changed your trajectory in terms of how you're providing service to customers or your channel partners or the workforce?

Bashir: Absolutely. In fact, during the pandemic was when we launched the first in the country, first in the nation, digital pathology program that allows us to digitize slides and upload them and make them available for care teams to work. That was the first in the nation. We did that. Of course, again, some of these are plans that were in place already, but they came to fruition during the pandemic and were helpful.

You would think that, of course, it makes sense because that's one of those physical space-bound processes where someone has to physically look at the slide and the physical slide, but now you don't have to do that with the digital pathology. Also, you make the information available to the entire care team. That's the other thing. Not only do you digitize your slides but also make the information available with other information that they need to care for the patients. That's an example of that driving digitization.

One other thing that our organization's been working on, for example, we have the first in-hospital 3D printing of joints. This was a project we did in collaboration with a European company to set up an FDA-regulated facility at the hospital to print the joints for acute procedures. Things like that, of course, you might think, "3D printing, is that digital?" Of course, it's all along the line of digital transformation.

In fact, I should mention also that the modern total knee replacement was developed at HSS close to 50 years ago. Being able to do 3D printing of implants for those acute situations is just in line with that tradition of groundbreaking innovation.

Saam: How about on the AI and machine-learning side of things? How are you using those technologies at HSS?

Bashir: That's one of the areas that I have seen really tremendous growth at HSS in the last four years. We've built a really good experience team of data analytics engineers. The cloud's really enabled us to jump start our efforts in that space, and it underpins some of the partnerships that we have in the industry today; some of those things I talked about and some other things that are in the works.

It really rides on the back of our analytics program because we're bringing data- we have a data link built in one of the public hyperscalers, we're bringing data in from our EHR, research data, we're bringing in genomics data, bringing packed in. Some of these things are actively in the works as we speak. Being able to build a platform because one thing I didn't mention earlier in terms of digital transformation is one of the critical elements of a successful digital transformation program is a platform. You need to build a platform and make that platform where you bring in all your data assets.

We're doing that. The cloud's enabled us to do that rapidly and quickly. We wouldn't have been able to do that as fast or as well without the cloud. We're doing that and that's allowing us to improve care. All kinds of clinical pathways have been developed based on our ability now to understand data that we have.

Evan: I think about AI. AI has changed a lot this week, let alone this month, this year, this decade. I see this crazy exponential growth curve. If AI gets 100x better, 10x, or 1,000x, or substantial better than this today, how does that change precision medicine or personalized care? What does that look like from the patient perspective 5, 10 years down the road?

Bashir: If we get it right, it's going to revolutionize care delivery from many dimensions. Access is one. We talk about the health inequalities that exist in society. The urban poor, the rural communities have restricted access to care. With AI-enabled treatment programs, you can take care of people that are in long distances from where the care providers are, whether it's using technologies with computer vision to analyze skin conditions to do radiographical analysis of images, MRIs, or CT scans.

All of those things would expand access, but of course there are challenges with AI, and we've seen some of those. Many of the models that have been developed in the lab, they do very well in the lab, and then when they put in the field, they don't do too well quite often because the models are probably trained and tested on data sets that aren't truly representative of the population out there that's going to benefit from them. We'll work through all those kinks but it truly has a potential to expand access to care, to lower the cost of care overall.

Evan: I imagine also in some scenarios getting to superhuman levels of diagnosis or treatment. At least that's what we've seen in other fields where at some level of progression, AI rise starts getting better than the trained experts can perform, so I imagine those unknown applications we'll get to see as time goes on.

Bashir: Absolutely yes, indeed.

Evan: I feel like AI is emblematic of just how fast technology is changing, and I think that probably all of us agree the technology advancements that probably lead to better patient outcomes, better patient experience for you, there's probably been as much progress made in the last 10 years than probably the prior 100 years or so, right?

Bashir: Absolutely.

Evan: That trend will naturally continue. Can you help us?  What does that look like? If I'm walking into HSS in 10 years what could that experience be like?

Bashir: Well, maybe in 10 years, I don't want to say maybe you would not have to walk into HSS, but [laughs] again in broad strokes, healthcare is a big space, and we are a specialist hospital. In broad strokes, healthcare in general is changing and it's going to change at a much faster pace as time goes on. The future of care delivery is virtual. We'll end up doing more virtually, we'll end up doing more in ambulatory settings meaning in-home settings, in clinical settings, without having to be in a hospital.

Hospital care is expensive. Hospital care has all kinds of challenges. We all talk about hospital-acquired infections. HSS, by the way, has one of the lowest infection rates in the country. That's one of our proud things. The future of healthcare has us consuming care virtually more and in ambulatory settings whether it's in-home or in a clinical setting.

To put things in perspective, for the first 150 years of HSS, we did surgery at the hospital. In the last five years, we've opened a number of ambulatory surgical care centers. Just think about that. For 150 years, surgery was only performed at the hospital, and in the last five years or so, we've opened a number of ambulatory surgical care centers, where now, you go in, you get that meniscus tear repaired and you go back home. You don't have to stay in a hospital setting. Ambulatory surgical care is lower cost, hospital care is fixed cost care. The payers pay more, the patient ends up paying more.

We're pushing more and more of the care to either a virtual setting, in-home setting. Many hospitals are developing in-home hospital programs where a patient actually would stay home and you would have some of the technology you need to monitor your vitals and everything else, and you have a care team that's virtual, watching and monitoring. We have, for example, Mercy Hospital. St. Louis-based Mercy Hospital is a fully virtual hospital that was set up a few years ago. It's a fully virtual hospital. They don't have your traditional hospital rooms, wards, and stuff. It's fully virtual.

That's the trend that's coming, and then, of course, precision medicine, being able to personalize care. Today, therapeutics work for some people, they won't work for other people. The pharmaceutical industry will tell you what percentage of people might benefit from a particular drug. With precision medicine, we're able to make better care decisions, better therapeutic decision about what care would benefit what people. We're able to better target diseases.

Finally, one point I should emphasize is we're now moving care to earlier stages of the care value chain, meaning there's an increased focus on wellness, whereas a lot of the cost in the US healthcare system is at the tail end of that healthcare value chain, after-care, when someone's really sick. Now we're moving more of the care to the beginning of the care chain, where focus on wellness, focus on prevention to avoid hospitalization, to avoid infection, and to enhance speedy recovery from disease.

Evan: Bashir, one thing we like to do is the lightning round just to get a couple quick hits so we can get some variety. How do you think an organization should measure the success of a CTO?

Bashir: It's in your ability to remove friction for your organization in terms of the use of technology. One of my areas of focus in the next several months is in what's now popularly being called the digital employee experience. It's an extension of your digital workplace strategy that focuses on digital employee experience, so making sure that we remove friction as much as possible from our employees' interaction with technology and meeting their expectations, consumer-like expectations that they have when using enterprise technology, and, of course, making sure that you're positioned strategically in terms of taking the organization forward technology-wise.

Evan: Of course.

Saam: Maybe to ask the flip of that question, what's the most common trap you see a new CTO fall into?

Bashir: Not keeping in touch with what's going on in the landscape. There's so much noise out there technology-wise, and you need to be able to recognize the music from the noise, and you need to be able to focus on what's important to your organization. On one hand, you want to keep the lights on, networks up and safe, but on the other hand, you also need to innovate.

Many times people would rely on true, tested, tried technologies and might not be willing to look at what's new or rethink the approach to infrastructure resilience or their thoughts about security and things like that. You have to be willing to just constantly evolve your thinking.

Evan: Bashir, is there one book you'd recommend any CTO, especially going into maybe a new job, should read?

Bashir: One book that I would recommend to anyone going to a new job is the Michael Watkins' First 90 Days. I would recommend that book to anyone going into any job or any role, even it might not be a new job. It's just a great book, provides a framework for approaching change, whether it's going on a new team or taking on as a CTO of a company, as a CEO of a big company. It's just an excellent book. Michael Watkins, First 90 Days.

Saam: What's the newer emerging technology you're personally most excited about?

Bashir: I've been interested in enterprise blockchain for a number of years now. I'm actually, on the HIMSS, blockchain in healthcare task force. HIMSS is the organization, the Health Information Management Systems Society. It's a large industry group. I've been on the task force over three years now, learning about the potential application of blockchain in the healthcare industry. I've written a few articles about aspects of that, whether it's in the self-sovereign identity or the potential use cases of blockchain in healthcare.

We're not there yet. There are a number of initiatives out there, there are companies playing in the space. In the last two or three years, as Web 3.0 has become more of a thing that we're talking about, people are beginning to-- It's evolving to become more of, "We're taking the ideas of decentralization that is present in blockchain technologies and applying that to enhance the popular web technologies, Web 2.0, that we're all familiar with." If it seems vague when you listen to different people talk about it or sound different from person to person, that's because it is still vague and everybody's painting a vision for what that would look like as they understand it.

Evan: I know much less about blockchain than probably anyone else on the call, but what is maybe one of the potential enterprise applications that you're most excited about for blockchain technology?

Bashir: One area, and I think that actually some initiatives that are on the way to try and get that going is in credentialing, or one of the challenges that clinicians go through, they have to be credentialed. They have to be credentialed every X period and across institutions. It's a very laborious exercise. The credentialing office at any hospital will tell you it's a tough job.

There are some projects out there that are looking to use the blockchain because it just lends itself to that. If I credential Dr. Evan and Dr. Saam, and I've validated that you're still credentialed to practice medicine in this area, why should they have to do the same thing over again? Why couldn't we leverage what's been done by one institution? There are some efforts in that space. In fact, a number of our institutions came together a few years ago including, I think, Optum. I think United was amongst them, a number of payers came together to set up a consortium to do that.

That's the thing. A number of consortiums have sprung up over the last few years to tackle some of the industry challenges. That way, they all put heads together, pull resources together. We'll see where it goes. There's that.

People have also talked about tackling the problems of counterfeit therapeutics, which is a big problem in many-- particularly in the developing world. There are counterfeit drugs in pharmacies all over Africa and other parts of the world. Leveraging the blockchain to track the provenance of that drug or any other thing for which you want to track the provenance, the decentralized nature of the blockchain can allow us to do that. There are applications like that.

What's also happening is that organizations are realizing that maybe it's not all a brand new thing on blockchain. Maybe we can leverage parts of blockchain technologies, which legacy technologies, and I'm calling them legacy technologies just because it's the things we're used to, we can use the decentralized concept of the blockchain with other technologies that we have. I think that's what's shaping to be the Web 3.0.

We went from trying to think that it's just brand new, completely different, to, "You know what? Maybe it's not going to be completely different." Maybe we'll take aspects of decentralized technologies and bring that, combine those with true and tested Web 2.0 technologies to create a new experience for users. We're not fully there, but over the next few years, I think we'll probably see decent adoption of some of these services.

Evan: That's right. I like what you said because that is true. I think about most emerging technologies, there's some kind of spark and then the intercession  of the spark in the enterprise application and some principles of legendary technologies that come together, that end up having real breakthroughs for the enterprise.

Saam: This has been awesome, Bashir. I'm really excited for our listeners to get to hear all your insights and experiences. Thank you for coming on.

Bashir: Thank you for the opportunity. It's great. You guys do fantastic stuff. Being able to chat with you about what's happening in my part of the world and in healthcare, it's a good honor and a pleasure. Thank you.

Evan: That was Bashir Agboola, Chief Technology Officer at Hospital for Special Surgery.

Saam: Thanks for listening to the Enterprise Software Innovators podcast. I'm Saam Motamedi, a general partner at Greylock Partners.

Evan: I'm Evan Reiser, the CEO and founder of Abnormal Security. Please be sure to subscribe so you never miss an episode. You can find more great lessons from technology leaders and other enterprise software experts at enterprisesoftware.blog.

Saam: This show is produced by Luke Reiser and Josh Meer. See you next time.