Luther Cale— Working to make healthcare safer, remote from Ecuador
What's it like raising a daughter in Ecuador? What's a good way to work remotely from another country? How do you build a new product in healthcare? These are some of the questions we ask Luther Cale, Vice President of Clinical Programs at Healthstream. Healthstream works side by side with healthcare organizations to ensure that their people are confident, competent, and credentialed according to the highest possible standards.
Luther talks about:
how CPR training has evolved
what's going to make virtual reality a viable education technology in healthcare
how to get customers to join you in your innovation process
and why everyone in business should work in sales for some of their career.
Listen in or read the full transcript below.
[00:00:00] Tom: Luther. It is so good to see you. Thank you for coming to the Fortunes Path basement.
[00:00:52] Luther: Happy to be here. Yeah. Good to see you. It's been a while.
[00:00:56] Tom: It has been a while. Yeah. You've been very busy. You now have a seven year old daughter and she lives in Ecuador. Is that right?
Luther: That's correct
Tom: So tell me about how that happened.
[00:01:08] Luther: Yeah, I live in a place called Kumbaya, Ecuador. Most people think I’m kidding - they think it's made up.
Tom: Sounds great.
Luther: It does sound great. It is great. It's a little valley outside of Quito. Quito, Ecuador is about 3 million people and it's a capital city - I think it's the only one in the world where you you land and it's 10, 000 feet up. But you see snow-capped mountains.
So it's just this amazing sort of combination of many factors, but the Valley is, uh, 70 degrees every day. If, and the cool thing about Ecuador is there's no real seasons there. They have rainy seasons and such, but not really what we think of as four seasons. So if you pick a nice weather spot, it's, it's nice all year.
Tom: That sounds beautiful.
Luther: Yeah. So I started in Ecuador. I went there in 2006 for the first time because I had read this article about the Valley of Longevity. This is a place where people, you know, purportedly live till they're 100 years old. Have you seen it? And uh, I was in marketing at the time, so I had to go see if that was real or if it was just marketing.
And it was real. This is a place with incredibly clean air and water and a lot of rich minerals in the soil and, uh, pretty low stress lifestyle. And so people, in fact, I saw lots of, I don't know if they were actually 100, but there were definitely, uh, a high population that was still living a vibrant life later in life.
And so that's what really took me there. During my trip there, I traveled all around Ecuador - specifically in the Andes mountains. And that was the thing that just sort of vibrated with my soul. I felt the pull of the place to say one day I'm going to move back here and live.
[00:02:39] Tom: So you, you have worked remotely.
You told me from 16 different countries.
Luther: That's right. Yeah.
Tom: So how well has that worked?
[00:02:46] Luther: It’s been interesting because I was well ahead of the remote working curve for COVID. It’s 15 years I've been doing it, and it's gotten so much better. Like there's never been a better time to do it than now.
It sounds so basic, but specifically the internet access is just better in so many places. We have fiber optic in the big cities in Ecuador. So up down is fine. But when I first moved there, I was living in this little valley - very remote - and they brought me a satellite internet dish that was about the size of a CD, and I just started laughing.
And it was not sufficient, so every week they would come back with a new dish, and it got to be, you know, about the size of this table, actually, and that was just barely sufficient. But it was the biggest one in the whole town, and so we've gotten a lot better with technology.
[00:03:32] Tom: That’s fabulous. There's a lot of hubbub about back to the office, and I know that your current employer, my former employer, Bobby Frist, built his dream office, and it is now… What, as someone who's worked in an office and worked remote, what's your opinion about the productivity differences?
[00:03:55] Luther: That's a great question. I was just there today actually, uh, the last several days, been meeting with partners flying in to see it and, they all observed the same thing that you just did, which is [the Healthstream office] beautiful and how sad that it's all empty. And it's a gorgeous spot. It's great for convening.
It's really especially great when we purposefully convene people. So in January 2020 we had two or three hundred people and then that felt like the old times, if you will. However, the timing of it was literally right before the world shut down. It was when we moved in there. So it had a very brief heyday of activity and moment.
As you alluded to, I've been doing these experiments for quite some time. So about 12 years ago, I convinced Bobby, to let me do just a little experiment with my marketing team. At the time there was a, idea in vogue called Rho,
[00:04:45] Luther: which is results only work environment. I remember that they had pioneered it at Best Buy and wrote a book on it.
So that took my attention. They gave me the authorization to do that. The idea is a, results only work environment: work from anywhere, anytime, as long as you get the work done and deliver the output and the outcome. And so I rolled that out to my team and, every single person on my team continued to come in the office except for me.
So, I maybe just implemented that policy for myself. I remember being down in Belize at Christmas and working from there and thinking, I'm never gonna spend another Christmas in a cold country at a cold location. And I don't think I have since. There you go. It worked. Um, however, I think we're at this moment where...
Executives and companies are trying to figure out what the right balance is, because I'm seeing some executives start to swing back the other way to say, all right, everybody's coming back in the office. And there's some examples here locally in Nashville where they've done that. I'm not going to be too popular with certain types of workers like tech workers.
So I think we're still in that wait and see period. If they require that, is that going to free up new talent to move on to other dreams? Uh, that sort of thing. I do think it'll never go back a hundred percent to the way it was. People have options, so if the options aren't presented to them and they're a valuable employee, they'll, walk to where there's value.
However, I'm at an advantage because I worked there in person, knew all the people, and then I can unplug and still connect with the people. I know them. I'm part of the culture. I've helped build that culture. All the new people that came in - and there were hundreds of them during the pandemic that may have never even met a person - that's a whole different, a very difficult problem to solve.
[00:06:27] Tom: An issue I'm hearing from, friends who take remote jobs is that, and you know, a lot of them are my age. They've grown up where you developed your relationships with people face to face in real life, as they say.
Now it's much more difficult to develop the political capital by doing it remote. For whatever reason, you don't get the same bond when you're not with someone physically. To ask for something that seems risky. It's like, it's, it's harder to step out when you're in a remote environment.
That's what they report. What's your sense of that? Having done both?
[00:07:10] Luther: I'm a fan of hybrid, but in a different way. I think most of the time when people think hybrid, they think, uh, two or three days in the office a week, that sort of thing. That's not really feasible for me because I live 2200 miles away, which I just had to remind my accounting group is not a commutable distance for tax purposes.
They were trying to, instead of reversing my expense, if it was taxable as part of my income. It was not. The hybrid that I'm a fan of is more aligned with how I do it, which is I come back to the United States once every quarter. I spend about two to three weeks. I very intentionally have put those two to three weeks together to pack them, stack them, and rack them as the great Fred Thompson once said.
I make a point to just stack up client meetings and partner meetings, employee meetings, and really get that sense. I just had this last week - some great brainstorming sessions, and I haven't had that great brainstorming session virtually. It's not that you can't create ideas virtually, it's just a more sort of maneuverable mechanism to kind of pivot, bring people in and really see where it goes. Whether it's two times a year or one time a year or four times a year or whatever it is, I like having almost like a little mini sprint, right?
Tom: An in person sprint, if you will. Yeah.
[00:08:30] Tom: When I was with you at Healthstream years ago, it was an idea factory. And a lot of those ideas did come out of hallway conversation. So there's a downside. I loved my time there, but there's a downside to like, oh, you're right there.
I'm going to tell you, I'm thinking about this thing. I'm going to tell you what's on my mind where you come away from those conversations when they're with leadership. And you're like, Oh shit, I got to change my whole agenda. Everything I've been doing is wrong.
So there is that excitement of the shared conversation, but it takes a while to understand what that is. I'm wondering if you have those less frequently and if you have them more intentionally. So is it more valuable to have the water cooler brainstorming? Intentionally four times a year than unintentionally potentially any day of the year?
[00:09:26] Luther: I think there's, two pieces to it. Another example I'll give is on our customer journey and customer interactions. We put together, a council that meets in person once a year - an innovation council. It's limited to 25 people. It's leaders from different, organizations across the country.
We come together with a very specific theme. It may be, Resuscitation rates have been the same for 50 years and we're not saving any more people. Prices are going up for that. How do we improve that situation? Like the whole focus of that council and committee is let's move the needle. Let's start saving some more lives.
Let's bring down prices. Let's make a better program. Let's innovate. And so we've been meeting every year for several years. Once a year in person, the same group, we bring in some new people from time to time, but it's a group that's focused on this problem for five years now. When we first started, we had a blank roadmap and some ideas, and in those sessions, we ideate. To your point, it's probably more things than you could actually accomplish.
So part of the session is built in, is really prioritizing to say, well, first let's build a better mousetrap. Let's create an alternative BLS, ALS, and PALS program for people to learn that skill. Secondly, after we do that, let's focus on preventing cardiac arrest. Let's not wait till they go down and be able to resuscitate them.
There's 400, 000 people a year that are dying that don't need to die because they deteriorate and it's not caught. And so we've just built a little roadmap and got priority from the group and use that to sort of sequence our effort. I mean, honestly, Tom, it's probably like a seven year roadmap.
These are solving big problems. It's not quick fixes, so we have to prioritize and get feedback. That's one piece of it, which I think the intentional once a year we've started to put in this year in November, we'll do our first, sort of virtual filler session where we can actually stay in touch every six months and update on progress.
But the other thing, the water cooler thing, I was thinking about that last night, actually the biggest challenge I've seen, specifically for that tranche of people that joined during the pandemic, is they miss out on key learnings that you and I sort of just picked up by osmosis. Like if we were in a meeting. I'll give you an example.
If the marketing guy came in and said, you know, we, in our industry and healthcare, the joint commission is a big entity and it's a big deal. So if that person is in a meeting with all our sales team, and he messes up: instead of calling it the joint commission, he calls it the great commission.
[00:11:55] Luther: After the meeting, I'd pull him aside and be like, dude, like you can't say that in front of the sales team, they'll cut you to pieces. In the virtual world, that just never gets addressed. I just move on to my next team meeting and everybody else does too. So the poor guy is, you know, getting up in his Ted talk seven years later, talking about the great commission.
It's awkward for everyone.
[00:12:20] Tom: That's a really good point. It is more difficult to give feedback in the moment. In a virtual environment, because there is no meeting after the meeting, and there's no pre-meeting either.
[00:12:31] Luther: And then you can, ask managers to be more intentional about it.
So I'm keeping notes on people, but it's still not as spontaneous in context. You know, like, it's like the old, uh, George Costanza when he thinks of the joke that was funny, many weeks later. It's like that: Hey, I want to talk to you about something I think you can get better at. But that was also three weeks ago.
I was like, why are you bringing this up now? This is awkward, right? Instead of just right after that meeting, a little quick bang, no big deal. And we move on.
[00:12:57] Tom: That's a really interesting point. You can see why managers want everybody to come back. One is that you can see them, and the other is that it makes the jobs of the managers easier.
But I'll say that there are people who absolutely depend upon their jobs being remote. For other reasons, you have an elderly parent, someone you're taking care of, you have a young kid, lots and lots of reasons. And some of them are just, it's so much cheaper than commuting. You know, I don't have to have two cars necessarily,
[00:13:26] Luther: etc, etc.
I think that's a big deal in Nashville. I mean, the cost of living has gone up so much that people do save a lot of money from not having to do that.
[00:13:35] Tom: So you're going to call me back in the office. Are you going to pay me more? Because you've just taken my real income and given it away.
[00:13:43] Luther: I'm going to come full circle to your opening question about my daughter. I used to have a configuration where I was mostly in Nashville and would occasionally or frequently even go to Ecuador for weeks at a time and then come back. I did that for a year or two years, maybe three. It was really difficult for me with a daughter in another country.
I felt like I had a divided heart. I loved my work and I poured myself into it. I love my daughter, but I couldn't be with her as much. So I reversed that configuration to now where I live there. Most of my time is there and with her and working there. I come back here occasionally, like, as I mentioned, that arrangement has been 1000% better for my happiness, my health and well being, and, I would even say my productivity.
[00:14:35] Tom: All of us are more productive when we're happier. When you have something weighing on you … we're all human. You can't help but have that affect your work. There's some expectation that work is totally separate from life or has been in the past, and that's complete bullshit.
Luther: I don't believe you can separate them.
Tom: Agreed. So I wanna go back and talk a little bit about some of the cool stuff that you're doing. You mentioned that innovation group, the 25. So I wanna give a little background on what that's about. I'm gonna call it C P R training. So this is resuscitation.
For anybody listening who doesn't know, resuscitation is pumping somebody's chest - we used to call it mouth to mouth. I don't think we do mouth to mouth anymore. It's trying to keep the heart going after it stopped. So you're beginning to use virtual reality in that training. Is that correct?
Luther: Yep. That's right.
Tom: Tell me what you've seen with that. VR is kind of a punchline. Certainly the metaverse is a punchline. Where do you see it in education?
[00:15:42] Luther: We actually had, a kind of a multiple modes of simulation and immersion in CPR training programs now, and it is having a moment.
There were several million people watching on January 2nd when Demar Hamlin went down on NFL Monday night football with a cardiac arrest and his team did perfectly. That professional medical team realized it was more than a football injury immediately. And that his heart had stopped and they did a resuscitation for eight minutes.
Then they put him in an ambulance and took him to the hospital. They had to resuscitate him again there. That team was trained by the American Red Cross and CPR and sort of knew the signs and jumped in. So every healthcare professional in the United States and our health system and our hospitals needs to have a certification that they can do CPR if they're on the clinical side of things.
It's a very important function in our U. S. healthcare system. And they have that card and maintain it. It, and that they train effectively in it and get better. So the, the first wave of innovation over the last, let's say 15 years ago was the introduction of, uh, mannequins that talk to you, you know?
So you're pressing on an actual mannequin that says, hey, you need to press harder, or your hands are in the wrong place - those kinds of things. That was a big advance. Yet you could be making three mistakes and that voice could only tell you to correct one thing at a time, and it might take three compressions, so it could be 10 compressions in by the time you've corrected all the things, and you're not even sure if you've caught up, you know?
So It was good, but really visual feedback is more incident-directed. The next wave of, innovation we've introduced, starts to tap into the technologies you're talking about, but even the mannequins themselves improved where there's blood flow and you can see the brain perfusion. You see the blood going from the heart and the brain light up.
A lot of people, even medical professionals that have been doing CPR and CPR training, were like, oh, it was a light bulb going off. They’d never really understood that their whole purpose is to get blood to the brain, and now you can see it happening. That was an advance. For the mannequins on the virtual side, we really focused first on leadership and team leadership because it's not just the compressions and the ventilations.
It's also, if you're the person leading the other five people on this crew, how well are you keeping things on time? Are you switching the people out when they get tired? Is the medication on track? Those are usually doctors that are leading that. So we created that one because it's a stressful situation.
It's, almost like all your emergency training, military training. Those have all been great applications of VR. And a lot of that technology came out of the DOD because they're training in realistic scenarios. So you want the right amount of stress. You don't want it just a little easy - like flipping through some PowerPoints to call it a day. You also don't want to be so stressful that you panic and you don't learn anything. So that's where VR is the sweet spot in training. Our first attempt has been to train team leaders. We did this in multiple hospitals and health systems and all ages and all groups.
I was watching to see how people took to it. In most all cases, I was surprised at the older generation of nurses who [nearing] the end of their career. On the way to retirement, they've really embraced this thing. That was a big shock to me.
Tom: It shocks me too.
Luther: Still, there were a couple that were like, I can't do it. But by and large, they've been through, gosh - in their career, you have to do it every two years. So they may have done it 20 times. And it's been the same old, same old. For them to experience the newness of it, they were saying things like this is the most realistic and best version of this training I've ever had!
That was rewarding. However, the, the healthcare industry as a whole is not there yet. So like any product adoption curve, you've got a few innovators trying to figure it out. I would say that was one product line that was the most impacted by the COVID stoppage. I was down in a hospital in Birmingham, Alabama, and had just finished the piloting that technology with them and they loved it.
I think it was the very next day, the world shut down. So there were two years that we had trouble getting back in hospitals to set up those labs, to get the feedback. And even during that time, Facebook also decided to shut down their Facebook for business program, you know? So the tools to administer it in administrative settings like healthcare systems was diminished or reduced.
There's still some catching up to do.
[00:20:13] Tom: What do you see as the biggest barrier to adoption for, I'd say as someone with a background in education, VR in an education setting makes total sense. You learn something, the more closely something is taught to you to the situation where you'll apply it.
If you're learning how to play golf, you're out on the course and someone's there with you, so it's easier to apply it than if you're watching a PowerPoint about playing golf. So VR is kind of the same thing. It can take what are stressful, dangerous situations and make them where anybody can experience them in a safe environment where you get feedback. The idea that this would have a positive benefit on training totally makes sense to me, but the adoption of it is like, first of all, the headset just looks stupid. So I'm wondering what are the barriers to adoption?
[00:21:13] Luther: Yeah, we've done some experiments with the different headsets, as you mentioned. I don't even know if HoloLens is still going to be a thing. I think they killed it, but we had that one. We had the Oculus, you know. We had all the Microsoft Mixed Reality ones. We had adapted our programs to all of them and just experimented with them.
The HoloLens was really cool and great at certain things, but the field of view was very limited. And they never really moved past that, where there's just like your horse with blinders on, essentially. It was good at certain things, but it wasn't complete enough to fix the whole thing.
The price has come down. So that barrier has been removed with a sort of Oculus questy type stuff, where the price point makes sense. A lot of the health systems I talked to - their dream is more along the lines of what you articulated, which is really just embedded in every unit.
It’s an evolution in education that would greatly help because it's contextual. So they have the idea in the past of sim centers and places you have to go specifically to learn things. And this would really take the things you need to learn to where you already are, which is the dream.
It hasn't happened, I think, because some of the administrative tools just aren't game time ready yet, but that problem will be solved here shortly.
[00:22:34] Tom: It sounds like culture is not necessarily a barrier to the adoption of VR. Maybe I'm the only person embarrassed by it. So is that reasonable to say you think culturally we're ready? It's really a technique tech issue.
[00:22:49] Luther: Yeah. The other surprising thing I had from one of my pilots was we had a sort of self directed VR session where there's no voice. You can choose to interact with it as voice or no voice.
We chose no voice. I saw some shiny, cool toys with voice and I was like, ah, man, we should have done voice because that's like part of the realistic experience. However, when I was actually in the training environment in the lab and they were putting six people through this program, they're all in different scenarios of different patient loads and six people were going through.
It was like a library in there - quiet as the mouse and if anybody had been talking, it would have been distracting to the learning environment. So in that particular setup and case, I was glad we didn't use voice, because it wouldn't have worked.
There’s a lot of little small operational details like that one, and then the headsets. If they go down, how do you get them back up and how do you update content to them? All those little problems that have been solved, you know, with content and content engines also need to be solved in VR to be, you know, completely viable.
[00:24:00] Tom: One of the things that's bedeviled educators for years is measurement. For a long time with e learning, the only measurement there was was multiple choice tests. We have progressed somewhat beyond that.
Do you see VR helping with the measurement?
[00:24:18] Luther: Yeah, VR is almost the opposite problem.
It literally measures everything. It's a more a matter of, of what needles do you want to pull out of the haystack? It's tracking your eye movement and exactly where you're looking and how you're responding to everything. Obviously some of that information can be interesting or it could be helpful even if aggregated, but it's way too much data.
I worked with a couple of academic medical institutions that are doing these eye tracking studies and all this stuff and you know, I'm a practical guy, Tom, so I'm just like, what are they going to do with all that information? I don't know.
They bolted on some of the stuff I liked in their proposals to actually measure clinical outcomes and see this thing making a difference. But it was really anchored in all this crazy, shark laser beam. Things I still can't wrap my head around.
[00:25:07] Tom: Yeah, I do feel that particularly in education technologies, they are often a distraction.
T your point about there being opportunities for bells and whistles where, you need to understand the context in which it's being used to make the decision let's not do voice that's going to be make adoption easier. And in terms of measurement, it's like, okay, we can measure where their eyes are going, but what's the point? No one cares. We don't, we don't know any information from that
[00:25:36] Luther: I mean, if eye gazing with you, would help improve clinical outcomes, then I'm interested in that. But there's some pretty awesome uses of VR.
With the HoloLens experiment, one of the things we were doing was looking at very high risk pregnancy situations. They're not incidents that happen very frequently, but they're very, very high risk when they happen. For instance, if the baby is turned sideways, can I experiment with, getting that in and getting it out?
That's going to be a very different experience on the screen, than just clicking things versus in a virtual reality or even with mannequins or a team simulating it I do think there's great value in, in practicing. You worked at Healthstream for some time and they've got millions of data points that basically say in some format, that you can get an 89 on a particular test about a subject.
Then there's data from the hospital side saying, I'm sorry, nurse Jane doesn't know what she's doing. Like how do we close the gap between those things? The only way is to practice in the healthcare environment, practice sometimes means a preceptor and you're following somebody and they're coaching you and that's great.
It’s the whole spectrum. You can practice a scenario with a pillow in a bed with a team, or it could be a hundred thousand dollar simulator that gives birth or it could be virtual reality, but we have to practice the scenarios. I mean, one of the industries that we look to as an analog is, the airline industry, that used to be, unsafe as hell.
Now the safest way to travel is in an airplane. How did they change it? Well, they did it with data. They have a black box in every airplane and it measures exactly why they went down. We knew the top 10 reasons. Number one was they missed the landing envelope and, they get a pilot in every six months and make them do all the checklists to make sure that they can beat it.
That's something that hasn't really happened, for example, in resuscitation, and many different safety areas in hospitals. Part of the barrier has been legal discovery. Interestingly enough, they don't want to, nobody really wants to publicize that, if somebody died that didn't need to die, nobody's going to talk about that.
What needs to happen is a culture that shares that information internally without the fear of being sued. So they get better at it. As a country, we got to get better at it.
[00:28:10] Tom: Yeah. There's a lot to those comments about the collecting of the data, the using of the data to create content.
When I was at Healthstream, one of the principles was platform/content/data, and that you had a platform that allowed you to put content into every hospital in the country and some, you know, many subacute, environments. Then you license content to them. Back then we used to talk about basic cable and then premium channels.
Then you could use the data to interpret. What should I do about this? I'm wondering how VR potentially changes that platform/content/data strategy, or if it's like no change at all, it's just an evolution.
[00:29:03] Luther: Well, again, to lean in on the data part for a second, that's just another area ripe for misuse, you know? So how can we use that in a way that helps prioritize what the problem is? I talked to one CNO recently who said I don't want to see another dashboard unless it's configured like this, like a warning light that you just screwed up something and it's blinking red at me.
The second thing, what do I do about it? That's all they wanted to see. And we create all these dashboards that looks like, you know, stock market charts, like I got 17 things in my portfolio and they're all equally weighted and I have no idea what I'm supposed to do. So there's a lot of danger there as well.
The airline industry example I gave is they use the top 10 there and they prioritize it and we have to do the same thing in medical. Last year, the Joint Commission started requiring in January every hospital to do two things. One. to measure, actually collect the real world data from the resuscitations and document that they've done it, and then two, to analyze it and have some group that's looking at it.
That will turn out to be a bellwether moment in time. As you know, from having worked in the healthcare industry, it isn't the Sprinter, it’s not the Usain Bolt of industries. There's always some people are ahead of that curve and killing it.
Then there's other people still looking around, waiting to see who's going to get dinged first and how severely are they going to enforce that? Am I going to have to do it in three years or this year or when, and just waiting. What we try to do at our organization is at least identify the innovators and start getting out ahead of these things so that when everybody else catches up, they have tool sets.
[00:30:38] Tom: How do you identify those people?
[00:30:41] Luther: That sort of co-creation of product is really, really difficult. Those innovation councils are one great way to do that because those are the people that care, so to speak.
[00:30:48] Tom: When you're putting that innovation council together, how do you decide who to ask? Talk to me just very practically - what is your asking process? Because everybody's busy. How do you get to agree?
[00:31:01] Luther: It's a good question. I think it's a little bit art and a little bit science. I hand selected many of those people myself with the idea in mind of how they might interact with each other. So it wasn't even just that they're with this big system or that.
It was like, okay, that person is kind of a muckraker and, is going to throw, little Molotov cocktails in our ideas and that's good. I like that. I don't want all of my, all the members to do that because you would never move it forward. But I think kind of keeping the group small enough where you can make those sort of handcrafted decisions if you will, and creating it is important for a council like that.
If it was 125 people, it wouldn't have the same impact and ability.
[00:31:42] Tom: I think in some ways it's closer to throwing a dinner party. You're trying to figure out.
Luther: I like that analogy.
Tom: You want people who can talk to each other, who are going to get along, find one another interesting and are going to talk to you.
The reason that they'll continue to, the first time they'll go is it's flattering to be invited to something, you know, you put this in my LinkedIn or whatever. And so, but if it's boring or it doesn't feel like it's going anywhere, you'll go to one, maybe two.
One of the things Bobby used to talk about that I always love was inviting customers to come on the journey with us. We're going on a journey. Come on, let's all go on a journey. One thing that was so great about that is it directs everybody towards the future. Whatever thing is bugging you today, you can go, don't worry about that.
Come with us on the journey. That's going to be okay. Let's not get bogged down on those kinds of details. Let's talk about the big picture. That approach in healthcare, can be extremely effective.
[00:32:47] Luther: Yeah, we put a lot of work into making them valuable. That's my litmus test.
If when we're creating the agenda, we're getting speakers and we're putting discussion topics together, is the CNO that came to this thing going to walk away and say, I'm really glad I just spent six hours doing that. Like that was a great use of my time. If they don't say that enthusiastically, we've missed the mark.
So far they've said it enthusiastically. Part of the reason is the journey comment that you talked about, because over time you do see, it's not just a bunch of BS. It's not just a bunch of twirling and, putting your name on a resume. It is actually working together with industry partners, associations, medical doctors, everybody that can both express what needs to be done.
In 2018, we had a blank roadmap, you know, in 2023, I've got nine logos of organizations contributing to that and seven new products that didn't exist five years ago. And so you can actually tangibly see as a member of that council, like I, you know, no single person made that happen.
It couldn't happen. It's a consortium, it's an ecosystem, but my participation is critical because I helped make that happen. I can raise my hand and feel good about that.
[00:34:05] Tom: Let's talk about that process of developing and launching products. You were referring to the new resuscitation product Healthstream released.
They'd had a long term relationship with a partner that went south and then needed to find an alternative in what felt like a monopolized market. Can you talk to me a little bit about how the new resuscitation product was developed?
[00:34:31] Luther: Yeah, that was a fun process. Essentially, there's probably two places that Healthstream constantly finds new ideas for how to make things better in the industry.
One of them is just plain inefficiency.There's so many processes still done by paper. You're still amazed that it's 2023 and people even use paper. But over time we've identified all these places where even Healthstream has a whole arm of credentialing business and that, in some organizations, they still have people who are just calling to verify that this doctor went to Duke University and this doctor has this credential, in BLS and ALS and this other credential that they say they've had so that they can privilege them to do surgery X, Y, Z.
That was and still is a manual process. It doesn't need to be like, that's a great place for technology to sort of lean in and, and solve the problem. The second category, which one was this one, it was truly a monopoly. There was only one provider and only one way to do it in the market.
We're talking 96% market share and what happened as a result of that was essentially that there's no incentive in a monopoly to improve things and prices keep going up. So Healthstream was really in the middle, going back to our customers saying, Hey, guess what prices went up 3% this year, 5%, 7%, and at the same time, the product itself wasn't evolving or innovating, even though we had eight or nine years of data back from customers saying, Hey, we'd like to see this. We'd like to see that. We'd like to, yeah, we would too. It just got to a breaking point where it wasn't about a partner specific. It was about the dynamic in the market.
Healthstream decided to play a catalyst role to, in this case, say we're going to bring choice and change to the market. By doing that, we know from history that two things will happen. One is that prices will come down. It'll just put price competitive. Secondly, innovation will start happening again.
Both of those things have happened. The winner in that equation is the customers, right? No matter what, it doesn't even matter who they choose at that point. Their prices are going to be better and their products can be better. That's been a very exciting journey.
Going into market in that kind of market environment against a near monopoly. What you had seen was in the nineties, there were all these sort of fly by night operations that came up that were like, hey, get your resuscitation credential online. You know, you pay them a hundred bucks and you don't do anything and you get your credential.
It was real shady. As a counter response to that, a lot of organizations, even at the state level, at the federal level, organizational level would write into their policy, the vendor's name that was required in order to do it. So we were coming into a competitive environment where now we had a credible alternative.
It's backed by the international liaison on resuscitation and core science. That's an international body and it was generated by the Red Cross, a scientific advisory council, which has 50 members that put in all the research to make sure this is the best and latest science for how to resuscitate, how to educate.
It was very credible. At the same time, we were going into state environments where it's like, yeah, you can't sell that product here because the regulations say it's got to be this one product that used to exist. The only reason that existed was because they were trying to counter that sort of shadiness.
We actually had to fight a lot of policy battles in order to open up all these markets. And, it got to be weird and interesting. We’ve now won all those battles is in 50 states and a million people have gone through it and have their credentials. It's been a big success, but every day was interesting.
[00:38:21] Tom: Did you use the monopoly story, as a way to win those state house fights? Luther: No.
Tom: How'd you win those fights?
[00:38:31] Luther: We those fights on the scientific credibility of the program. For example, the US military, all active branches had switched to the American Red Cross Program.
Every single person coming out of every branch of the military was coming out of them as HealthStream continued to make progress in some of the larger health systems in the country. Switching to that program again, because of the innovation, the cost change. We continue to kind of pile that evidence back.
So it was a virtuous, uh, positive cycle.
[00:39:02] Tom: There's also some momentum behind that. So it's like Colorado says it's okay to get it from Red Cross. Then you send a letter to the, whoever the regulator is in Connecticut and say, Oh, Colorado is just says, okay. And so it starts to build momentum because it's getting the first one to switch is probably the first two or three. It's excruciating. After that, it begins to get a little quicker.
[00:39:24] Luther: I remember being on one of those policy boards in the state of Texas and it was dicey down there to the last second. Somebody, felt like it was if we worked in Washington DC and we're in the political world because right at the last minute, one member on the board is asking a question that's completely irrelevant, trying to derail the approval so that they'll say something like, hey, let's delay that vote.
And until next time, which might be a year from now and a year matters. We had a counter move for that, which was calling the director that's leading the meeting while he's leading the meeting and texting him and getting it back on track. It's challenging when you enter those waters.
I remember when we got it, it was, I hadn't really done that much myself. But I felt like I just, you know, gave birth. It was like, I was sweating. I was relieved. And I was also glad that I didn't go into politics.
[00:40:17] Tom: It's stage management. That sort of leads to the question about launching products.
We talked about [how] the development of that product came out of an established need and there was already innovation from a scientific and research standpoint that wasn't making it to market in the dominant product. There was an opportunity to improve the experience and the outcome.
By applying this, what was at that time sort of dormant knowledge, now you, you've got your better mousetrap. But, the market is used to the old one. How did you approach that to build adoption and get people excited about it? Or was there already a certain sort of built up resentment?
Like they were like, you know, I've been using this thing for 20 years. The price keeps going up. It's really not any better.
[00:41:11] Luther: These numbers aren't exactly right, but it's indicative. I would say 25% is just going to say I'm staying with the old no matter what you tell me, no matter how great it is, no matter how much money it saves me, I'm with the old, like, okay, uh, 25% to your point had some either resentment built up or they're just ready to try something better or new, 25% ready to experiment, and the rest, 50%, they don't really care one way or another. They're just waiting to see how the chips fall, you know? So We just made an effort to engage strongly in that first 25% and get the momentum because it was a matter of reflecting. I remember the first time I built a map, it was like the first season of the Simpsons.
I don't know if you've ever gone back and watched that, but the animation is really crude, the voices aren't really as good and it really evolves over time and gets a lot more polished. I created the Simpsons version of the map and we had sold eight, you know, so I had eight stars on the map. I put a little red cross on there and it was very rudimentary, but it started the feedback loop where I could reflect that back to other organizations.
Put 14 on there, 20. And now I think there's over 5, 000 facilities. I can't even keep up with, I can't even map them anymore. Part of that was just, you got to start where you start, start with seven, you start with eight, 15,000.
[00:42:35] Tom: I feel like those initial customers are absolutely critical. Did you guys have to give it away at any point? Was there a point where it was like, just please God, we'll give it to you for free.
[00:42:45] Luther: We did not. But you might remember the price had been going up. So price was a big factor in launching successfully.
[00:42:53] Tom: And so you did, you never gave it away, but you may have sold it at a discount.
Do you believe in things like loss leaders, that some things are worth selling, even if you might not make money on them? I do. And what are the right circumstances for them?
[00:43:08] Luther: I was working with a partner today where, there's a thousand critical access hospitals that are rural in our nation and they don't have access to the same kind of resources as the big systems that we're used to here and in the city and Nashville and all the big cities.
They're struggling. They don't get the best pricing for any programs. They don't have all their latest technology necessarily. They sometimes need the educational programs even more than the big centers, and yet they're most disadvantaged because they're not buying in bulk.
One of the things that we've started is to say, how can we put together special programs just for them to make sure the need is met? One of the ways we're starting to do that this year is through buying technology where they can pull together with others and say, basically for the next 90 days, we're going to give you the best price in the nation on this stuff.
If you get in now and make sure you have access to it. It becomes publicizing it to them. Make sure that you're working through the association. So all the members know you're working through your own marketing channels to make sure that they know, so they don't miss out on it.
Cause it would be a travesty six months later. They're like, I would have done that. I didn't know about that. Now I haveto pay the full price, you know? The goal is to get people what they need.
It's not to like maximize your, your profit on those segments. It is to also say, we've got this thing and we can help them.
[00:44:39] Tom: There's also a trip. So those small hospitals, don't have a lot of money, but they have a lot of political capital. There’s a lot of benefit of doing a solid for rural hospitals because there are an awful lot of people in Congress who have a little hospital in their district and numerically it adds up.
To your point, I feel like so much healthcare is politics. More than 50% of every dollar, in reimbursement and healthcare comes from a government entity, state or federal.
[00:45:15] Luther: It was speaking at a conference for the VA. I don't think there was a single presentation there that I watched - I probably watched eight or nine of them - that didn't start or focus with that market in mind and specifically call out their plan for rural hospitals.
[00:45:37] Tom: The VA is in the same situation. Their funding is dependent upon Congress. They're trying to appeal to as many Congress people as they can.
I want to wrap things up with a couple of questions. Some that are to make you reflect about what you do differently, but before I get to that one of the things I always loved about working with you is that you have really good taste in software.
And there's so much bad software in the world. What's some software that you're using now that you're excited about?
[00:46:08] Luther: I don't know, man. I used to be the guy that tried 35 productivity apps. And we tried this one and try that one. I've really gone minimalist I just try to use as few things as possible, I guess you could say. I use the Things app on my iPhone. I think it's a really well designed piece of software because it's super simple.
The main thing I want when I'm trying to download my ideas is speed so I don't lose them. If I don't write them down, I will lose them.
Things is really agile at doing that. It’s one of those secret powerful things. It does a lot more than you would think. It looks simple on the surface, but you can manage lots of projects and they can be embedded in each other and they can have sub checklists, but it does all that in a visually simple way.
So you're not overwhelmed. Like, Oh my God, there's way too many options. I experimented with Notion, and to me, it just was so complicated. I don't know. Maybe I'm just getting old, Tom. I think if I had more free time to be more of a geek, like I used to, I probably would love Notion.
In the end I just stayed with Evernote because it did everything I needed. It made bullet points. It made one, two, threes. I've made bold. I could send it out. So I've just gone a lot more minimalist and simple.
[00:47:27] Tom: So Things is one of your,
[00:47:29] Luther: Things3.
[00:47:32] Tom: Yeah, that's a good one.
I like that one.
[00:47:35] Luther: Believe it or not, you know, I've always kind of leaned towards Apple, but over time, I really do think Microsoft has come a long way with their core suite, even just the basic Outlook. I used to, bristle at having to use the Outlook suite and PowerPoint and Word. They've really made a lot of progress making those just sort of efficient and sleek.
They get an undeserved reputation because some of the features built in those things are incredible. It's not even bloatware. It's just like whoever invented the copy paste feature, the paint, uh, format feature. I want to gift that person 20 bucks on the internet.
I want to buy him an Italian meal or something. Probably don't need 20 bucks.
[00:48:20] Tom: That's the best feature ever. Copy and paste format.
[00:48:23] Luther: Format this like this is already formatted.
[00:48:26] Tom: It is a pretty good one. That's absolutely true. So I want to think a little bit about - you've had a lot of different jobs in technology.
You've been in marketing, you've been in product management, been in strategy. When you look back at the beginning of your career, do you have any regrets? Is there anything you do differently?
[00:48:53] Luther: For months, I meet with the interns at our company. Now we've got over a thousand people. So I get a chance to sort of reconnect with what life was like when you're just starting out and you're trying to think through how to navigate your career. It's fun for me cause they ask questions and I get to coach them and give them some thoughts on these kinds of topics.
And I always tell people, if they have an opportunity to go in sales and start in sales or try sales as a summer job or all that, I really, really recommend that. I hope my daughter goes. The reason is because as an entrepreneur, as a business leader, as a manager, like it's, you just need to understand that feeling of like, that's what puts food on the table.
Like you got to sell something. I remember my very first experience as a salesperson, I went to the account, I think I might have even worn a suit. Like that was back when people wore suits to, you know, look - that's a professional and I showed up and they slid an agenda across the thing. I was all, you know, thinking I'm shiny, like big man, uh, account manager or whatever it was called.
The first thing was recommendation, uh, cancel contract immediately and get full refund. And so that was my introduction into sales. And that was obviously a very uncomfortable moment. But those are moments you need, honestly, to grow, to understand what it's like to be on the frontline, answer very difficult questions.
That's helped me as a product person and to launch products, to having had that experience to think through, because what I see now I've launched many different products through many different sales teams, and that always can feel that nervousness when I'm first introducing a new product. You want to think that their response is going to be, this is awesome.
I'm going to make my quota. I'm going to change the world. But what you really feel is that sweat nervousness of, I'm going to be sitting in front of an OR director or an OB nurse, and she's going to ask me some question that I have no idea about. And I'm going to look like a dumb ass.
It helps me think through in advance, and maybe even ask some of those nurses and OB nurses what questions are you going to ask about this thing so that I can arm them. It's a little bit of coaching to be like, we're at day one or day zero. You're not going to know the answers to all the questions.
Here's eight. We've anticipated, 90 days. Every 30 days, we're going to touch base, share our information, and we're going to evolve just a little bit together, you know, so now all of a sudden, it's not scary that I don't know. It's exciting because I'm bringing back to my whole team, Hey, I got this, question or objection and here's what I said.
And then somebody else, Hey, here's what I said. And we're sort of pooling knowledge and like, man, I really liked how Jennifer said that. That was great. I'm going to use that. Or I saw Luther do the webinar on this thing, and I never thought about that angle. I'm gonna take that. So we're all just evolving together with intentional meetings every 30 days.
At the end of 90 days we've sort of worked out the kinks. There will always be changes, but we've landed on the formulas like, Hey, let's maybe not position these three ways. We thought that was gonna be good, but it wasn't. People are really interested in this, this, and this.
[00:52:01] Tom: When, when you're launching a product, do you ever tweak compensation, like first 20 sales get double penetration?
[00:52:08] Luther: Yes, I do. You try to make that a point.
Tom: I read an article once that said, the CEO's job is to help make sure the first 15 sales come in. And I really liked that concept.
Luther: I like that idea too. I consider myself - I'm not the CEO. I'm like a mini CEO. I have a piece of the business within the business. I always make sure with our big product launches that I'm in there, that I'm in there on the meetings. I just launched a new product. So again, with that roadmap, It's not just about responding to an emergency.
The next innovation in U.S. health care is let's prevent that from ever happening. There's 400,000 people a year that die preventable deaths that are clinical deterioration-related. They're declining and it wasn't caught in time. It's the type of thing that you can't put the genie back in the bottle.
If you're waiting for a hospital system to alert you, it will do that. But by the time I'd alert you that they're declining, it's really too late to go back in time and put them in a better situation. So the time to really start that process is when they get admitted and you need a framework to really understand, what am I looking for?
The operating system question is, how can Mr. Smith die today? You know, how could he decline? I'm thinking that in advance, but I've been trained in this program that says, Hey, it's not infinite, the number of ways. People can die in hospitals. There's 15 fatal conditions and really all of them boil down to four pathways and any of those four pathways can lead to cardiac arrest and death.
Which one is Mr. Smith on? Oh, he's in a circulatory decline and so therefore I'm going to look for these certain things showing up and if they happen, I'm going to run diagnostic tests. I'm going to intervene in the correct way. So I partnered with a doctor from California that created this brilliant program and has worked with 11 different hospitals and achieved amazing results and published the data of those in several scientific journals that say he can reduce by 50% the amount of cardiac arrests that are happening in non ICU units.
So it's there. We have the formula. Part of the process is really engaging people about that.
[00:54:15] Tom: The cynical part of me is going to jump in for just a second. So will the hospital make more money if fewer people die?
[00:54:22] Luther: It's interesting when you say it this way, the cynical person in me says we're almost to the point with this, data that we've collected where we can say if you implement something like this, you can expect to save this more many lives and some CFO somewhere may be calculating is it worth it, which is awful to think about.
[00:54:43] Tom: Well, we're not paid for outcomes. I think one of the things that really helps adoption of changes in healthcare is a regulatory tailwind, and one of the things that really prevents innovation in healthcare is a reimbursement headwind.
I'm trying to get to the end of the podcast: it's sort of debatable in the American healthcare system, but what is the purpose of healthcare?
I have a presentation I give salespeople selling into hospitals and the first slide in the presentation is that the purpose of the American health care system is not to make people well, it's to produce a bill and get paid. That makes clinicians want to vomit.
It makes me want to vomit. But people who operate hospitals look at it that way. It's the classic no margin, no mission. Um, and no mission, no mission. Anyway, so I think being able to explain why is it in people's interest to reduce the number of deaths by 400, 000 is in their economic interest.
[00:56:06] Luther: If you're talking to a risk management officer, a financial officer, there are several pieces of that educational program and operating system approach, if you will, that tied directly back to the value based purchasing formula that you're talking about. If you can reduce overall mortality, your profit margins in your hospital will be better.
There's sort of a case in all cases that's emotional in nature. Like, hey, this is the right thing to do. There's also a clinical case to be made that not this many people need to die from sepsis because this is catchable. And then there's also a financial sort of data risk case.
I do agree with you. I've spent probably five or six years of my life more on the health side of things, what I would call what does it really look like to be healthy and eat healthy and exercise and maintain a health weight. A lot of people in that industry really can refer to the healthcare industry as a disease care industry,
It makes sense. Right? I get your point, what you're saying. If I were to go into our healthcare industry and say that I helped prevent clinical deterioration, they're going to think about what the program actually does, which is looking at all these risk factors and disease decline.
If I went back to my old health community and said that, they'd be like, okay, you're going to stop eating cheeseburgers. Right. Because that's really declining. That's prevention. You're going back more to the root cause of how we ended up in the hospital declining.
[00:57:42] Tom: You should come back and have a conversation about health.
[00:57:43] Luther: We probably need a whole different podcast to focus on that theme.
[00:57:47] Tom: That's right. That'd be fun. Luther, it was a lot of fun having you. I appreciate you coming.
[00:57:51] Luther: I appreciate it. I'm here any time. I'd love to do it again.