Stop Polishing Cannonballs—A Conversation With Dr. Michael Ash of Nebraska Medicine

Q: You’ve had quite a career—starting as an internal medicine physician, moving into health IT at Cerner (now Oracle), and serving as a chief transformation officer before stepping into your COO role. How have these experiences shaped your leadership approach?

A: I've always been interested in technology since a young age. I started out in engineering but quickly switched to pharmacy school and then medical school. In residency, technology found me again. While at Baylor College of Medicine I worked on a Palm Pilot-based application called PatientKeeper that was ultimately acquired by HCA (and is now part of Commure). Then I went into private practice, and being a pharmacist found its way back—I became the chair of the Pharmacy and Therapeutics Committee. While working on my MBA, I was recruited to Cerner by their chief medical officer at the time, and I ended up staying there for over a decade.

I eventually decided to return to the provider side. Having kids and ties to the Midwest, my wife drew a geographic radius and said, “Keep us in this area.” I trained with the chief quality officer of Nebraska Medicine who recruited me. When I came here, I oversaw quality, safety and IT principally, and within a couple of years we improved to where we're in the top five for safety and we achieved HIMSS Level 7. When our previous COO took a CEO position at the University of Cincinnati, that created the opportunity for me to move into my current role.

In the early days, I was driving technology as a subject matter expert. Now I’m in a position where I have the privilege of having a large team across the organization that supports our efforts, and my job is to determine what our problems are and what are the potential solutions. How do we improve operational efficiency? How do we improve quality and safety? How do we improve the overall experience? How do we positively impact the financial bottom line? My most recent focus is on operational excellence and the role of technology there, including AI.

Q: Nebraska Medicine has built a reputation for innovation, from the Davis Global Center to the new Innovation Design Unit. What are the organizational or cultural elements that make these efforts possible?

A: I love that question. In our community there's a rich history of innovation—instead of Silicon Valley, this region is often referred to as Prairie Valley. At Nebraska Medicine, our values when turned into an acronym is iTEACH, where “I” stands for innovation. If you look at our partnership with the University of Nebraska Medical Center, some of the first bone marrow transplants of their type occurred here. Every academic medical center has innovation, and that's part of why they're so important to society, but I think for us it really is part of our DNA.

Regarding the Innovation Design Unit, as we look to the future of our campus renovation needs, we want to get it right. No one has a crystal ball, but we really want to look to the future to see what care could become. Care is too important to not evolve, and so we made the decision to remodel a unit in partnership with the donor community to build this space where we can test not only what demos well, but what's truly useful in improving matters of quality, safety, the patient and provider experience, and ideally the bottom line.

Many of the problems that health systems face, even pre-pandemic, have accelerated. As our population ages, and the burden of chronic disease and the subsequent requirements on care grow, we need to figure out how to provide care differently. If you look at studies published by Johns Hopkins, one of the top three causes of death in the United States is medical error. If you look at several things that occur within the hospital, like sepsis or patient falls, there should be no such events. So, we're trying to see how to focus on people, process and technology factors to be transformative in a way that hits our goals.

I think you can't walk on our campus and not see things like the Davis Global Center and other innovative examples and not appreciate the role that many people across the organization play in these efforts. Regarding the Innovation Design Unit, there were over 800 people that gave input to that, and it's really been not only a moment of pride, but a beacon of hope for what would be the environment that they get to provide care in going into the future.

Q: Let’s pivot to talk about digital governance. From EHRs to AI, how does Nebraska Medicine structure governance and oversight? How do you as a COO fit in that structure?

A: Governance is challenging. We haven't perfected it, but we look at it like a diamond shape—you have the top-down influence, and then you go from the point of care and move up and across the organization. Many governance structures don't take both into effect. That's part of what we're trying to work through. Our governance is inclusive of the senior leadership team, and we meet every two weeks.

From a top-down perspective, we’re figuring out what are the big problems that we need to solve. How do we improve access? How do we improve operating room efficiency? Etc. Then we use executive committees that are coled by an operational person and a clinical chair for core areas (eg, surgery, acute care, ambulatory). Those individuals have a set of key performance indicators (KPIs), and we also use objectives and key results (OKRs) to refine questions like how we run our business and how do we need to change our business. They're helping to identify where there are needs, where there are opportunities, and then we are working as an organization to figure out if we have a product set that can be transformed into a solution for them or if we must go to the market. From a bottom-up perspective, where the care is occurring, what's the process by which people say we can eliminate waste and inefficiency if we introduce this technology? So that's how we're trying to look at it from a diamond perspective.

Regarding roles, people are trying to figure out titles to provide clarity and remove certain barriers. If your role is around AI, that provides a level of clarity and that helps, but you don't want it to inadvertently create obstacles (eg, does that mean only this person can think about AI or move something forward?). We're interviewing different leaders from other institutions to better understand these things and learn how others are framing their governance to most efficiently and effectively address challenges.

In the near term, we're not running these as IT projects, but rather as operational projects. In fact, we're attributing the annualized cost as if it's a capital project. So, if I don't save the cost equivalent of whatever that annual spend is on AI, then I'm going to reduce my capital budget an equal amount.

We also need to focus on where there is the biggest ROI. Technology is transformational and no one is short of ideas of where it can go, but we’re trying to send a clear message that speed to execution matters. I think of it like using cannonballs versus polishing cannonballs: What are the problems that we're really trying to address and how do we most efficiently go and tackle those (ie, using the cannonball) versus doing needless incremental work (ie, polishing the cannonball).

Q: Many health systems are now seeing promising results from AI pilots. Are there any AI applications that Nebraska Medicine is actively deploying or scaling? What has made these particularly valuable?

A: There are a few key areas that we're making huge bets on. We are always Epic-first where possible and especially around clinical applications. We’ve also been partnering with Palantir since January 2024. When I became the COO, we had about 600 different projects around the organization and we narrowed our focus to a few key challenges: We were losing more money than we were making, we were losing more people than we were hiring, and our perioperative space was not operating where it should and risking surgeons that were threatening to leave. We focused on those areas to turn our red indicators green, and we’ve really had a turnaround.

Using Sg2 data, we had seen a reduction in tertiary and quaternary cases, in particular transfers from other health systems, and we were seeing challenges in getting our more complex surgical cases scheduled because of inpatient capacity constraints, so we launched a team around inpatient capacity. We did some unique partnerships with post-acute facilities, we launched initiatives around eliminating admissions in certain areas, and another big focus was shortening length of stay.

One of the opportunities for shortening length of stay is the utilization of the discharge lounge. We had been using a discharge lounge for about eight years—our record was three patients in one day. It was usually about three patients a week. We started using AI to identify patients who qualified for discharge and then created workflows that had a push and a pull to create a process to get those patients to the discharge lounge. We eventually saw a 2500% increase in the discharge lounge. Then there’s the staffing. We in the Midwest are still using contract labor and we have premium shift differentials for weekend, evening and overtime. We started using AI to determine how we can build the best schedule—interfacing information from Workday, matching competency needs for that unit, staffing it based on people’s preferences so they're happier, and then doing it in a way that's also cheaper. That's where we've seen a lot of financial ROI.

We then expanded into the revenue cycle. Everyone's hiring more people to deal with the challenges of insurance companies. We don't take the position of eliminating staff, but we want to slow the need to add more staff for administrative tasks and so we’re figuring out how can we use AI to help with appeals letters, utilization management, preauthorization, etc, and we've been very successful there.

Additionally, we started using the Nuance DAX solution back in 2019. For 2025, we're doubling down on that to see if there are opportunities to improve the quality and thoroughness of documentation and do it in a way that's less burdensome to physicians.

The biggest promise for AI is around early diagnosis and treatment. How can you improve the accuracy to above what a human is capable of? Huge promises there, but in the near term, we’re focusing on what's realistically achievable with the technology that's available to us today. From a quality and safety perspective, we’re focusing on what Epic is doing in this space. The big bets are around operational excellence and making it a better experience for the providers and the patient.

Q: You’ve already touched upon ROI, but let’s dig a little deeper. How do you evaluate which technologies are worth investing in, and how do you justify them at the executive level?

A: I think of it like balancing cost accounting versus financial decision-making. What cost can I eliminate to justify that new expenditure, and then financial decision-making is about what can I invest in to achieve a future state? We're trying to balance that.

Regarding access, within the OR we're using AI to read the surgeon's notes to better understand what they’re planning. If they say they're doing gallbladder, but they're also doing hernia repair on a morbidly obese patient—looking at this surgeon's prior performance—how much time are they likely to need? We feel by improving the accuracy of our scheduling, this could add hundreds of cases annually. Regarding AI for bed planning, the OR staff used to spend 30 minutes twice a day saying these are the surgical cases planned, these are the bed requirements needed—that’s now all “auto-magic.” The physician that was leading our utilization management was spending 40 to 50 minutes per case reviewing the chart and information—now it's less than 8 minutes. With transfers, staff can predict how many discharges are planned today with incredible accuracy, and so it improves our ability to take transfers from an outside organization.

If you talk to the people using these solutions, it's eye-opening to find out some of the paper cuts they had to deal with before that are now gone. We're seeing that in many other areas, which is really humbling, and it's evolved our thinking on how to not only determine ROI but do so in an empathetic and humane way for the person making decisions with a high cognitive burden.

We see a lot of benefit that you might not anticipate when you sign the contract. We looked at the five-year cost of the Palantir contract, and our goal was to have a full ROI in two and a half years because we feel that much of this technology will be commoditized by the core vendors like Epic or Workday. In our first year, we attributed over $10 million worth of hard value, and we're very confident we will recoup that five-year cost ahead of schedule. Part of why we're being so purposeful there is that it allows us to work on other things that might not have a financial ROI but are still truly beneficial to the organization.

Q: With AI looming, how do you approach workforce planning? Have you had to rethink roles or training to better align with new technologies? Do you find that staff are generally receptive to this change?

A: Never underestimate people's ability to block something. You must own that from the beginning. If people don't want to change or if they want something to fail, if left unchecked, that will happen. The last thing you want is to get an e-mail that says, “Tell me the five things you did last week,” right? You don't want someone to think you're just looking for ways to eliminate their job, or that they’re never going to get a raise again because AI is more efficient. I think if you don't own that fear, and you don't own those concerns out of the gate, you're not going to be as successful.

I think you must be very purposeful, culturally speaking. If you're not purposeful about making your organization ready for change, it's not going to work. One of my favorite quotes is, “You can't jump a 20-foot chasm with two 10-foot leaps.” You can have good technology, but if you're not thinking about that other side—boom. You need to bring the people along who are ready for change and are looking for something better on the other side. So, we really create a space where our senior leadership team listens to the people that are giving reports on the technology, and we're being very purposeful on the sustainability of the technology. Ultimately, it’s about transforming people’s lives and improving the care we provide. I’m blessed to be at Nebraska Medicine and the University of Nebraska Medical Center.

This blog post is part of an ongoing Q&A series with digital health leaders at organizations across the US. These in-depth interviews aim to provide real-world perspective and insights in this rapidly evolving space. Don’t miss the first blog in the series, found here.

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