A year ago, the idea of using no-code software development or truly portable electronic records in health care seemed years off. But for Intermountain Healthcare's new CIO, Ryan Smith, the pandemic has changed that.

Ryan sees the trends that had been emerging in the years before we were all stuck inside and argues that the digital revolutions that have already come to other industries, like banking, are on the way faster than ever for health. What's missing in medicine, though, is a national support structure and strong federal regulation to push legacy providers into the digital age, he says. The impetus for change may well come from Big Tech, with companies like Apple, Google and Microsoft taking a greater interest in health care. And the possibilities for what we'll actually be able to do with all that data once it's easily accessible are near endless. "We're really just at the tip of the iceberg," Smith said.

Protocol recently launched its Manual on the future of health care after the pandemic and hosted a panel with experts from across the industry to discuss how COVID-19 has already upended so much in medicine — and what will likely stick around after the dust settles. Smith — who had previously spent 19 years at Intermountain Healthcare, left in 2013 to pursue roles at other health systems, and recently returned as CIO — was one of the panelists.

Protocol spoke with Smith after the panel to hear some more of his thoughts on what the future of health care will look like after the pandemic.

This interview has been edited for length and clarity.

What's it been like starting in this role during a pandemic?

Well, it's been really interesting. Everything's virtual: All my onboarding with senior executives, my own direct reports, everything's just video visits, by and large. It's working — keeps things very focused. It feels a lot like a crash course, when you come into such an innovative organization such as Intermountain Healthcare, that has so many things going on — there's just an awful lot to learn. And I'm really appreciative for the 19 years I spent at the organization, up to seven years ago, but a lot has changed. It still feels a lot like drinking from a fire hose.

What are your goals in this new role? What challenges do you want to take on?

I think if we boil it down to probably a small handful of items, really positioning my team to help the company with its growth initiatives. Transparency is going to be a really important thing for me: A lot of IT organizations get criticized for being a bit of a black hole, in terms of sometimes the priorities they're working on, how their budgets work, and I really want to make sure that my team is really tightly aligned with where our senior leadership is taking the company.

Beyond that, security, privacy, those types of things — you call them table stakes, but they take a lot of time and effort and investment to get right. And that's an area that I'm absolutely committed to, of really being conscientious and careful about how we stand up systems, how we treat data and how we work with IT vendor partners.

I've heard from a lot of IT organizations that there's been this kind of no-code/low-code movement recently, empowering other departments to take some of the load off of IT, building their own solutions to problems. Has that come to health care yet?

No — it's coming. We might still be at the tip of the proverbial iceberg, but I'm seeing more of that, in terms of things like self-service analytics. Instead of having a whole bunch of data analysts that have to be in the middle of every business intelligence and data reporting and analytic requests, increasingly we can get curated data models, systems and tools, especially visualization tools, in a self-service way. Technologically savvy individuals — it definitely doesn't take software engineer-level or data analyst-level people — [can] really get in and use those tools to do a lot of things, like cohort analysis, managing their operations, etc.

It's an area that has a lot of early interest, but quite frankly, I think health care does still lag a lot of other industries from that perspective. [There are] probably some pretty good reasons for that. When you look at the complexity of our data and our workflows in health care, the high level of regulation, it does make it more challenging to have these low code/no code kinds of tools.

What does the future of portable health care data look like? How do we get to a place where it's easier for patients to be able to better understand their health — is the solution continuing to work with big players like Cerner or Epic, or are there more-distributed solutions ahead in the future?

The vendors do have their role to play as it relates to interoperability, but if you peel some of the layers back just a little bit and you think of the monolithic architecture of those EMR and EHR vendors systems and their platforms — the high-level modules, the capabilities that ends-users interact with — [they] are so tightly coupled with the underlying architecture and infrastructure. They're making a lot of progress towards opening up their systems and giving more APIs, web-service layers, [and in] some limited cases direct access to the database structures. But inherently, if you think about it, these organizations aren't necessarily heavily incented to really open up their systems, because what that's doing is signing up to be disintermediated by more-innovative players.

It feels like in our industry, and I'm just generally speaking, some of the vendors do a much better job than others, but it feels like there's still a pretty tight rein of control around the level of access they're really opening up. At the same time, there's obviously a lot of federal pressures for data interoperability, but the government itself hasn't gone so far yet to be specific enough from a standards perspective that it really forces the level of interoperability that the country needs.

I'm hopeful that we can keep making rapid progress through policy and decisions at the state and federal levels. But I think to your point, a lot of this I believe ultimately is going to get done through consortium collaborations and private entities that are working to solve this challenge where real incentives lay, in terms of really enabling value-based care, reimbursement models and things like that. We just have to advance this interoperability equation at a much, much more rapid pace than what historically has happened. And, quite frankly, I think the pandemic is helping to accelerate that pace.

I recently saw how inflexible some of these things really are. My family was trying to figure out what medical records of my parents to keep, all of which were only available on paper printed out from doctors' offices, that theoretically, I should hold onto for the next 30-40 years in case anything happens to me. This feels untenable, especially in a future when everything else is so digital.

You're exactly right. On the bright side, even down to individual private physician-owned clinics up to very large integrated delivery systems like Intermountain Healthcare, the country has seen the digitization of the health care record in a really significant way.

The challenge though is still having that interoffice data interoperability. That really still today is a problem across the country. Different organizations are working hard to address that within their own geographies or referral areas, or partnerships that they have. But it's really challenging. If you happen to relocate your family to a different part of the country, that health care record is still really challenging.

We're seeing companies like Apple make some inroads into that. We're certainly seeing health information exchanges trying to help with that problem. But what we still lack is really this national support structure, like a national patient identifier, which would really help around the interoperability side, but more importantly, having the data standards that really permeate across all of these different electronic medical record systems and other systems, to help link it all together. The banking industry got this figured out a long time ago, and they wouldn't have been able to survive had they not gotten it figured out. Granted, medical data is, I would suggest, 100 times more complex than financial data.

This data is just so personal. I do wonder if it will be companies like Apple, which seem to have built their brand in recent years around data privacy, that figure it out.

I think you're right. The really big cloud vendors, they're challenged in that they don't have the level of health care expertise yet, but they've been eager to get into this industry. There's definitely some inroads being made that, I think, ultimately really help our industry get further digitized, and it can work electronically at much greater scale, by virtue of these cloud models and data analytic models that these companies really bring to bear.

But companies like Apple take their consumers and the absolute protection of data they hold a lot more sacred than maybe some of their peers. And therein lies the problem with these big cloud vendors really getting in, not fully understanding or being fully transparent, how some of that data and information will be leveraged for their own broader business purposes as they're forging these strategic alliances with different health care providers. It's an area that we've all got to be really conscientious and careful of, and understand what our consumers' appetites are around the protection and privacy of their data and their information.

What do you think AI's future in medicine is?

I'm a firm believer that data — and how we can apply analytics in particular, AI and machine learning, to that data — is really the new frontier of health care innovation. We'll still see innovation even around financial and reimbursement models and things like that, but at the end of the day, even those will be informed by better insight into the data

When we look at caregivers, physicians and nurses in particular, we have thrown a lot their way as a country in these last 10 years. We have forced through regulation for providers to have to come in and do order entry and have to electronically sign prescription refill requests; they have to do all their documentation in the electronic medical record. And that has really changed the nature of how physicians practice medicine, both in the hospitals as well as in the clinics. And it's not the only cause certainly that's contributing to physician and clinician burnout, but it's definitely an additive.

When we look at things, opportunities like conversational AI, being able to have a physician walk into an exam room, being able the whole time to keep direct eye contact with the patient instead of her back to the patient while she's charting in the electronic medical record with an occasional glance over the patient … Imagine having both hands free, making eye contact, having a very personal experience and talking through that examined workup that is being captured through conversational AI.

I think we see AI playing a big part in our ability to automate a lot of things today across health care operations and central-office functions. Things that are very human latent, very manual, tedious kinds of tasks. That will help us continue to provide higher levels of service and quality while also working to reduce the cost structure of delivering health care services, which is a key part of our mission.

These are just examples of how I think AI is going to be applied: helping with clinical trials to speed up delivery on those trials, being able to analyze a lot more data from much broader populations. We're really just at the tip of the iceberg, and everything else lurks below in terms of this massive opportunity around leveraging data. I feel like that's really going to be the next massive wave in health care from a transformation perspective.