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HIStalk Interviews Fred Powers, CEO, Dimensional Insight

November 30, 2016 Interviews 1 Comment

Fred Powers is president, CEO, and co-founder of Dimensional Insight of Burlington, MA.

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Tell me about yourself and the company.

The company was founded back in 1989. There are two founders. We have built the company organically. We have no outside investors.

We tend to focus in industries which have complex data. Our very first customer, in fact, was a dental implants company. Back in 1990, we showed them where their product was being bought and where a competitor was taking away market share.

From that very beginning, we have expanded. About 15 years ago, we entered healthcare, which is now a major focus for us. We are focused on rules and measurements so that we can bring integrity to measures so that they are accurately displayed so that decisions can be made.

What is healthcare’s maturity in using data to make decisions as compared to other industries?

In any industry, you have some that are the leaders and you have some that are bringing up the rear. The sense is that healthcare lags behind industries as a whole. I don’t think that that’s really true.

I think that the difference here is that the data itself is more complex. If you go into a distribution company, you’re basically looking at all of  finance and then you’re looking at product going into the warehouse and product leaving the warehouse.That’s one data domain, and in a typical manufacturing or distribution operation, it’s a finite number of domains.

When you move over into the area of healthcare, it becomes much more complex. Each domain by itself is relatively easy to understand, but when all of a sudden you have 50 of them, you have different stakeholders, and the data crosses these domains — that’s where the complexity comes in.

Healthcare is complex. People have been looking at this problem for a number of years. It’s just taking healthcare a little bit longer to solve some of these complexity issues that don’t exist in other industries. Certainly electronic health records have helped because we’re gathering this data. That would be a change. But if you look even at the electronic records, there are hospitals that have had that for 15 years and some that came on board only a couple of years ago.

Healthcare is getting a bad rap when people are saying that they’re way behind times. It’s just that their data is complex, in terms of all of these different domains and all of the different stakeholders that they have that they have to satisfy. If you’re going into a distribution center or manufacturing, you might only have one or two plants. If you take a look at healthcare, you might have 20 different facilities, maybe more, and all that has to be consolidated, and yet it has to be broken apart as well. There’s a challenge.

What lessons were learned from early healthcare data warehouse projects?

The short answer is that they don’t work, but that’s because you’re attempting to solve a complex problem. Quite often, you’re better off if you chip away at the problem with a collection of data marts. The concept of bringing all of this data together has been around for well over 40 years and it’s always been a problem when you attempt to bring it all together into one place.

I do believe that what’s happening with the data warehouse is it’s going to move more towards a columnar database over a relational database. The reason for that is that you have more flexibility with the columnar database than the relational. It also handles higher volumes of data. Right now, as this data is collected, you have to ensure that you have integrity throughout the process, and the more data that you bring together and attempt to digest, the harder it is for that integrity to take place. You really need to decompose the problem.

Here at Dimensional Insight, we’re using a columnar database for our storage vehicle. If you do research between a relational and a columnar, most of your research is going to come back and say that for a data warehouse-type approach, this is actually a better approach. There is a tremendous amount of momentum in terms of what was done in the past and then bringing that forward.

Just having proper data is really not the issue. You can ensure that you have integrity of data. Your bigger question is, do you have integrity in terms of your rule management? If you’re looking at, let’s say, an admission or a readmit, what are the rules for that? Are they consistent across the hospital? How do the underlying rules relate to the measures that ultimately you’re scoring yourself on? Because something like an admit is used across a whole collection of additional measures. Does your measure equal what CMS says or is your measure slightly different, your rules slightly different?

This is now an area that the hospitals are going to be looking at, where before, they were just saying, “I just have to get some data into my data warehouse.” Then what do you do with that data? How do you measure? That’s where your measures come to bear. We use the term “measures.” Some might use “KPIs.”

The underlying rules are very complex. We could probably spend another half hour just talking about rules management. I can honestly say that these rules are more complex than what we see in industry as a whole. This is going to be the big issue in the future.

It kind of fits under “data governance,” but the word here is “data.” I think it’s probably better if you were to call it “measure governance.” I’s more focused, because if you don’t have these proper measures, how can you manage? This is going to be a real issue as we move forward.

Then they have to be centralized. Hospitals today are buying a lot of what I call point solutions. Each one of these point solutions has some BI in it, some dashboards, and of course this is based on a collection of rules and measures. What happens if those rules and measures in Point Solution A don’t agree with Point Solution B? Which one is right? Do you have a central location for controlling these rules and measures? How does that affect the point solutions?

Over the next two or three years, we’re going to start to see the industry look at this and say, “I’ve really got a management issue here that I didn’t realize I had, because I was pulling the data out of my data warehouse.” Let’s assume they have a data warehouse. The rules were not in there, or if they were in there, it was just piece parts, and now all of a sudden, I don’t have integrity when it comes to those rules. This is going to be some interesting times for these hospitals. In my opinion, they really haven’t given enough thought to that.

How much help do hospitals need in understanding their available data elements and then finding low-hanging fruit to give them a faster payback?

Each hospital is in a different position. Larger systems will no doubt have some form of a data warehouse. They’re wondering how they can maintain it and how they know it has integrity. You move into a smaller hospital, they might have no data warehouse. They have no governance. Depending upon the environment you’re in, it’s going to have a difference in terms of how you approach the problem.

We have some customers that are small hospitals and they’re trying to see their data for the very first time. They’re really not interesting in doing anything that’s fancy. You know, “Just give the numbers. I’ve been blind. Show me the numbers over time so that I can at least see trends.” Then you move into a large entity and they’re interested in doing more because they’ve already crossed that threshold.

That’s another challenge that we have from healthcare. When you go over to industry as a whole, they’re all pretty much kind of at the same level, where when you move into healthcare, that’s just not the case.

Obviously, whether it’s a large entity or a small entity, the goal is to pick some problem that they have and then solve that problem. Then solve the next problem and the next problem. It’s kind of like eating one grape at a time. If you attempt to eat too many grapes at once, if you’ve got a young child, you know that that’s not a good thing. We try to avoid that.

Let’s focus on something that’s important, something that you need today, and then what data sources you need for that. Let’s ensure those data sources have integrity. What rules are required? What measures are required to support that need? Let’s make sure that’s in place.

Let’s ensure that you have the necessary support staff, which I might add, is not necessarily IT. A lot of it will be a nurse practitioner, as an example, or a doctor who has left the fold and now they’re into the analytics and they understand what’s necessary. They understand the data. Quite often an IT professional might not understand that. They’re more a technologist. You need that business manager. This is a real issue because a lot of hospitals don’t have those people.

Is the key to analytics adoption providing pre-built applications or perhaps finding a data-curious department expert or that rare technologist who wants to work with users to answer their questions?

It gets down to where are they on the adoption curve. Let’s assume that this hospital is just starting out. You want to give them a package containing a collection of measures, predominantly CMS, so that they can track where they are. Now, if it turns out that they have history — which they should have, depending upon when they converted, because quite often when you convert, you leave your history behind with the older system — they can go back and look at how those metrics have performed over the last two or three years and which way are the curves going.

Executives obviously like this a lot because they can see the trends. You’ve got to get something in front of the executive quickly, because he or she has to buy into it. They have to see value in it. At the executive level, they’re interested in a certain amount of information and they want the ability dive into the underlying detail. Then your detailed analyst obviously might want even more information, and they become what we call a diver. In other words, they can just go in and they can swim in this data however they choose to understand what they have. But without question, you need the executive.

The other thing that’s happening is herd mentality. We’ve been doing this since 1989 in a multitude of industries. Let’s say that you’ve got an early adopter and they’re doing their thing. Then you’ve got another early adopter and then you’ve got three and four and five. Pretty soon, you start to get this herd mentality, like everybody’s got to do this. That’s what’s happening in healthcare. If you went back 10 years, you still had the problem. People just didn’t recognize that they had to solve the problem.

Now you have a certain amount of herd mentality. “Oh, they’re doing this at this hospital. That’s pretty cool. I think I have to go do that.” You can’t leave the emotion of the decision-maker out of the equation. There’s a lot of emotions in these decisions. Hospitals tend to be very political.

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November 30, 2016 Interviews 1 Comment

HIStalk Interviews Bill Anderson, CEO, Medhost

November 21, 2016 Interviews 1 Comment

Bill Anderson is chairman and CEO of Medhost of Franklin, TN.

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Tell me about yourself and the company.

I have been associated with Medhost for about seven years. I’m currently the chairman and CEO. Prior to that, I was involved in a number of different businesses. Going back to 1990s, I was an early participant in writing home banking software.

The company is in two businesses. We’re in inpatient healthcare IT and consumer engagement solutions, including the YourCareEverywhere.com website.

You have a fair number of small and rural hospitals as customers. What does their world look like today?

The world is tough in the community hospital market. We divide the hospital world into three buckets. The large tertiary care hospitals that are building communities of care — it’s largely Cerner and Epic territory up there. There are the small standalone facilities that are probably under 50 beds that are CPSI and Athena territory. We compete in the middle market, which is a full-service hospital, but without the complexities of the tertiary care hospital.

They’re not under as much financial stress as the smaller hospitals, although they clearly have more financial stress than the big tertiary care hospitals, which financially are doing much better. Still, there are a number of suburban rural hospitals that are under stress right now with the decline in inpatient volume, the increased fixed costs for regulation, and the insurance risk that they’re having to take on with readmission penalties and things like that.

Does economy of scale favor the huge health systems to the point it will become impossible for small communities to keep their full-service hospitals?

Clearly there are economies of scale. One would like to think that at some point in time, there would be allowances made for that. I’m not sure that’s literally going to happen.

There’s clearly overcapacity in the industry. I think as many as 40 percent of the total hospitals and 30 percent of the beds will probably be taken out of the system ultimately.

When people question that, I go back to the 1980s, when I was in the financial services industry and banking business. There were about 18,000 banks in the United States. Today, there are about 6,000. A lot of the same things were happening. Technology is changing how people use their hospitals, just like they did with banks. I would ask people, "When was the last time you stood in a teller line?" You had increasing regulation, and with the technology, place became less important.

I think there’s going to be a lot of disruption in the hospital market. Still, there are going to have to be geographically convenient locations. In the middle market, there will be winners and losers, but in general, we’ll continue to have a robust community hospital market.

Hospitals provide community pride and large-scale employment to a different degree than banks. Who’s going to figure out the economic answer to having access in communities that can’t support what they already have?

There are two answers to that. There were economic issues and community pride that were involved in the banks that went away also. Economics tend to override those types of things.

One of the reasons we offer our community engagement solution is that hospitals are going to have to build an affinity with consumers outside their normal community. There’s no reason that a hospital can’t build the same type of relationship with a consumer that’s 50 miles away that they did with people in their local town. You just can’t do it by putting billboards up. You have to be able to move into the modern age, do digital marketing, things like that. Not every community is going to have one, but you’re still going to be able to have a sense of community with your community hospital.

Consumers are going to welcome self-service, just like they have in other parts of the economy. For many things where you’ve had to have hands-on visits with a clinician, due to the shortage of clinicians and due to the inconvenience involved, you’re going to see things like telemedicine starting to take a real position in the marketplace. There are going to be alternative delivery channels, not just stand-alone EDs and urgent care centers, but also, the Minute Clinics and those types of things. You’re going to see a diversification of healthcare delivery that’s going to improve the convenience and hopefully the adherence with patients.

One of the things that I thought was interesting recently, because we have a condition management program, is that the federal government has allowed the YMCAs to get reimbursement for things like chronic conditions like diabetes. You can go on the YMCA sites and see that they run diabetes management programs to try to help pre-diabetics. This would probably not have been something that the healthcare delivery system would have been in favor of years ago, but it’s a consumer-friendly type of initiative. Let’s move these types of preventative programs and maybe even some care programs out into other venues so that consumers have better access to them.

The last time we talked, you identified McKesson Paragon and Meditech as your EHR competitors. How has that changed?

If anything, it is firming up. In the large tertiary care hospitals, the battle is probably over. Cerner and Epic largely own that space. It’s based upon the fact that those particular type of big facilities are building communities of care that do complex types of procedures. They offer robust products.

At the smaller end, in particular in the critical access hospitals, they can’t afford a lot. They have to look at total cost of ownership. Somebody could give them a program, but because of the total cost of ownership with training and these types of things, IT requirements, they need a pretty straightforward solution. We’re in between there. We have pretty robust product. We would have what I would call segment-appropriate features and we’re focused on trying to meet the needs of that segment. The battle lines are pretty much in place.

One issue that should be interesting to people in the industry is that we are currently in a lawsuit with Epic. Epic has an interoperability platform called Care Everywhere that is essentially sold with the full suite of Epic products. They’ve got a trademark on it. The trademark, of course, relates to an interoperability product. We have a product called YourCareEverywhere.com, which is an online health and wellness content site, which the Patent and Trademark Office was getting ready to issue a trademark on. Epic is taking us to federal court to block the PTO from issuing that trademark.

In our opinion, the trademark law doesn’t support that. In our investigation of it, we found some other interesting examples. For example, there’s a primary care physician group in Kentucky called Primary Care Everywhere and Epic is also going after them. There’s a company called Access Technology in Texas that has a product called Powering Care Everywhere that does billing for home health that they went after and Access filed for a declaratory judgment in Texas to keep them from doing that.

This is just another example of Epic’s bad behavior of using their market position to bully people around, or at least in my opinion. What they’re trying to do is to broaden their trademark in the courts as opposed to in the PTO, where they wouldn’t be able to do that. Given that your readership is largely people in the industry, they’re probably reasonably interested in Epic’s continuing bad behavior.

What was your reaction when McKesson announced that it was looking for a buyer for its enterprise business that includes Paragon?

I understand why McKesson did that. The RelayHealth business was a terrific business, and I think the deal they’ve done with Change is, for McKesson shareholders — from somebody who’s not an expert but is looking from the outside — a great deal. What they have left, though, is a collection of assets — it’s not really a company — of which Paragon is one. Paragon has about 198 facilities — not that thought about it very much [laughs] –and on the average, they’re smaller than our facilities. In a world where scale is important, that’s a sub-scaled business.

Probably the most interesting thing to happen lately was that Cerner, Meditech, and Medhost all exhibited at the Insight conference. McKesson, for obvious reasons, withdrew their support. The fact that that actually happened is indicative of where the Paragon product is going.

How are modest-sized health systems addressing population health management and consumerism?

We certainly hope they’re addressing consumerism by working with us, with co-branded sites, marketing services, condition management, and things like that. Population health is a term that means what individuals think it means. There are  two aspects of it. One is managing the population. There are hospitals doing that in the analog way out there in our market today. They’re having things like diabetes clinics and clinics to help people with heart disease and COPD. They’re trying to help people and manage the population in the analog world. We’re trying to give them tools to help do that.

The other side of that is, I’m going to take the insurance risk on these. When you hear about population health products from our competitors or other participants in the industry, what they’re really talking about is, how do I analytically manage populations that I have insurance risk on? How can I identify high risk people? How can I reach out to them? How can I see if they make progress?  In the middle market, that’s less of a need today than it may be in the future.

If I’m a big urban hospital, chances are at some point in time, I’m going to be part of an ACO, or because I’m big in things like hip replacements and I’m getting bundled payments, so there will be more need to be able to manage these types of bundled payments and things because they do more sophisticated systems. The needs for population health depends on what kind of facility you are operating.

Everybody agrees that managing a population requires data from outside the four walls, and lack of that data can be interpreted either as a reasonably evolving market state or an indication that someone is intentionally blocking data. Does data blocking exist?

I do in fact believe that there is data blocking. Some of it is not with bad intent. Some of it is a natural result of the tort law system we have in the United States. Nurse notes and physician notes could be pretty sensitive  in the context of potential litigation. People have legitimate reasons for wanting to manage the information flow.

Having said that, ultimately people are going to have to recognize that this is the patient’s data. The patient is going to get care in a number of different venues. It’s probably not going to be a supportable decision to say, I’m going to block the patient’s access to their information in a convenient way that allows them to pick their venue of care. It may take one of these lawsuits that I’m not particularly fond of to establish that that’s a dangerous thing to do.

For instance, if someone comes into an emergency room and there is information available that is being blocked that would affect the care and something happens to that patient, arguably the person who blocked the information contributed to whatever bad happened. The regulations and the laws support the fact that that’s the patient’s information and this whole Balkanization of data is a bad thing. I don’t think it’s actually been driven home to some of the providers that there is exposure in that.

Can the argument be made that interoperability would create the same universally beneficial outcomes in healthcare as it did in banking?

Yes and no. People are sensitive to banking information, too. Interestingly enough, when I was at H&R Block, I had the first credit card that allowed you to download transactions. There were actually two, the Web card and the CompuServe card. In fact, I have a patent on that, which Block never enforced.

At the time we set that up, people said, "I don’t understand why anybody would want to download transactions. Just geeks would want to do that." The reality was that everybody that ordered through a catalog — nobody was ordering online back then — wanted to know when their stuff was shipped, so they watched their credit card bills. There were economic reasons that the average person wanted to be able to see that transaction.

There are going to be reasons that the average person is going to say, "I have to be able to get access to my medical records." The easiest one is, I go to a new primary care physician or I go to an urgent care center and the first thing I have to do is I have to fill out 20 pages of information about my health history. I should be able to have access to my medical records and my health history so that I don’t have to do that, because I will probably as an individual do not such a great job of that.

There are differences in healthcare, but once the consumer gets involved with managing their own care — which is starting to happen in a big way right now — they’re not going to tolerate this Balkanization of data in healthcare any more than they would have tolerated it in other places.

One of the most bizarre things that you see out there is that a patient may be getting care from the same entity in three or four different places. Let’s say I go to an inpatient facility, I go to a specialist, I go to my primary care physician. They may all work for the same company, but I may have three patient portals. Only in healthcare would you ever see something like that.

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November 21, 2016 Interviews 1 Comment

HIStalk Interviews Robert Lord, CEO, Protenus

November 16, 2016 Interviews No Comments

Robert Lord is co-founder and CEO of Protenus of Baltimore, MD.

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Tell me about yourself and the company.

My co-founder Nick Culberston and I started Protenus when we were both in medical school. We started in response to a big problem that we saw in healthcare, which was that with the rollout of electronic health records, there has not been an effective attendant rollout of privacy and security measures to protect that data, particularly from an insider threat prospective.

Nick and I had backgrounds before healthcare as well. He was a Special Forces operator for the US Army. I was a quant at a hedge fund. We had seen a very different way of tackling the problem of insider threats, protecting VIPs, co-workers, all of those individuals from abuse of their PHI. We built a platform that could shift the paradigm of how we protect patient privacy.

What insider threats are you seeing and how prevalent are those compared to high-profile cyberhacking incidents such as ransomware and phishing?

From our own tracking and independent research, we see that a pretty consistent 40 percent of incidents are linked to the insider threat versus the external hack. While we think that there’s a lot of good work that’s been done on the external side — you see a lot of development in the space — there’s a lot less thoughtful work that’s been done when it comes to insiders, particularly in a healthcare-focused way. That’s been a big challenge.

Healthcare has a huge number of idiosyncrasies and challenges that are unique to the industry. It requires a deep understanding of the workflows and special challenges that the healthcare providers have, like the need for open access to records, the fact that individuals can have irregular workflows and patterns of activity, and the fact that there are huge amounts of data streaming through all of these systems and often in ways that are difficult to understand how they relate. It  takes a different approach, one that can integrate big data techniques and machine learning to get a better handle on this challenge.

Is there a higher likelihood of reputation-damaging behavior from insiders rather than outsiders since the person responsible was given explicit trust as an employee, doctor, or business associate?

Charlie Ornstein of ProPublica did an interesting piece on this. The individual, one-on-one breaches do the most damage because they are more personal, more focused, and more likely to lead to liability and bad blood between the hospital and the affected party.

A big hack from an external actor — whether it’s a foreign government or an individual — or an exposure of a database online can affect a huge number of patients. However, the most acrimonious and reputation-damaging incidents are these insider threats. It’s not just a theoretical exposure, but someone intentionally doing something with patient information, and patients react differently to that. When it’s that close to home, it hurts in a different way.

We know in healthcare that these systems are terrifyingly insecure and vulnerable because of the generally open access architecture, but a lot of patients don’t really appreciate that fact. They’re flabbergasted when they see this type of insider threat from someone in the circle of trust for that hospital.

That’s the big challenge. All of this is a question of trust. If patients start to lose that trust, if we have a crisis of that trust, then what are the implications for the larger system? Hospitals understand that at some level, but we don’t always see the attendant investments and awareness, sometimes at the C-suite level. There’s a lot of reasons for that, but it’s an interesting question that we’re going to have to tackle, both at the individual institution level as well as at the federal government level as they think through mandates of how to improve these systems.

What are some examples of issues your system has detected?

Obviously to protect our clients we can’t go too much into specifics, but the types of things that you see typically in this space include the classic co-worker breach, where individuals look at each other’s records inappropriately. It can be the VIP breach, where you’ve got a big movie star coming into your hospital and suddenly it seems like everyone wants to go check out their face sheet. 

Unfortunately, we’re also seeing the rise of criminal actors and criminal networks acting inside electronic health records, whether that’s directly having someone in there who is stealing records and diverting them to the black market or if it’s bribing individuals to divert those records to the black market. That has happened for as a little as $150 per record.

Obviously these are some pretty scary vulnerabilities. We’re seeing more and more of it. Then there’s the whole question of what happens to the records afterwards. They can be used for a terrifying array of threats, whether that’s identity theft, medication fraud, Medicare and Medicaid fraud, medical blackmail, or traditional identity theft types of operations.

Does every industry have the same insider threat problem or is it caused specifically in healthcare by insufficiently granular access?

Healthcare unfortunately suffers from a bit of a double whammy. On one side, the information within healthcare is some of the most valuable information that you have. I’m a member of the Institute for Critical Infrastructure Technology and we just released a report on the incredible value of electronic health records on the Dark Web. While there’s a lot of variability, the bottom line is that there are incentives because these are very valuable records.

On the other side, hospitals are pulled in a lot of directions. Those directions don’t necessarily include privacy and security when it comes time to budget. You got so many competing demands for rolling out new electronic health records and associated systems, different informatics  programs, obviously you’ve got the Meaningful Use incentive programs and MACRA. What you’re seeing is hospitals saying, I’ve got to do all of these different things and I’m not really sure where to put privacy and security on the roadmap, But simultaneously, if you don’t put those on the roadmap, in the long run you’re going to degrade the trust that allows those other programs to be successful.

Hospitals are caught in a tough situation right now. Health systems in general are trying to navigate those waters as effectively as they can, but it’s quite difficult. That’s what is leading to these breaches, in addition to those open architectures, the ease at which people can access this data, and the historical lack of technologies in this field to detect and thwart these types of threats.

What kind of normal user behavior does the system learn in being able to identify exceptions?

We take information from the EHR record and from the patient record, then weave it together with access logs, metadata, and a lot of other information that allows us to understand the second-by-second pattern of every single user in the electronic health record. By doing this, we can detect threats that go outside the traditional rule-based paradigms.

It’s never just one thing. It’s usually an entire constellation of things. The types of patients they’re treating, the types of actions they’re taking, the manner in which they’re moving through the medical record, and the amount of time they’re spending in it. Everything from the very simple to the extraordinarily complex.

With a big data platform that uses some of the best in machine learning and artificial intelligence and a lot of the advances that have come out there recently, we’ve built this ensemble anomaly detection system that incorporates a lot of different perspectives. Not just a single type of scenario, but a lot of different ones. We’re able to find everything from the simple types of threats, such as co-workers or family members looking at each other, all the way to extremely complex threats that we wouldn’t really have a name for, but as soon as you see it, you realize this is extraordinarily bad. The type of actor who might during the day have appropriate access to a certain department, but in the evening, on a particular workstation, or when looking up a particular subset of patients, their actions are inappropriate. It’s a subtle difference that won’t be caught by more basic analytics.

What kind of integration is required to put together the package of information that allows you to make that detection?

Our team has a lot of experience in the big data space, data integration, and doing this type of at-scale analysis. We’re investing heavily in our ability to do data integration easily. What we ended up building was a platform that could ingest data from any number of sources and be source agnostic, both in the number of sources as well as type of source. We then can push everything up to a more universal data schema and analyze from that layer. That way we avoid a lot of the laborious integration that often happens with other systems. There have been a lot of advances in technology that have allowed us to look at the data more from a first principle standpoint and then figure out exactly the elements that we need on a dynamic basis, instead of a highly manual and specified basis.

Do you have any final thoughts?

Healthcare is fundamentally facing a crisis in trust in our systems. We’re increasing the amount of data we collect. We’re increasing the analytics that we’re performing. We’re increasing interoperability. We need all these things to deliver the promise of better care, better patient satisfaction, and decreased cost. In no way do we want to stand in the way of all of this great data-sharing.

Simultaneously, if we can’t build that trust in the system, if we can’t establish a new paradigm for how we’re going to protect all this data and make sure people are accessing data appropriately, then we’re going to lose all of these benefits in the long run. 

As both privacy and security wonks as well as data scientists, we’re really excited here at Protenus about being able to push forward those advances in data science when it comes to privacy and security, just as they’re being pushed forward in improving patient care. I think that’s a big trend that we’re seeing and something we’re very hopeful about. 

While we think that in the immediate future things are probably going to get a little bit worse, in the long run, we’re going to have a much better system. Maybe even better than those in other industries, because healthcare is going to be tackling the hard problems first.

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November 16, 2016 Interviews No Comments

HIStalk Interviews Bill Corsten, President, Agfa HealthCare

November 14, 2016 Interviews No Comments

Bill Corsten is president, North America of Agfa HealthCare.

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Tell me about yourself and the company.

I’ve been at Agfa HealthCare since September of 2014, but I’ve been in healthcare IT for just over 20 years, about half of that at McKesson Corporation. I grew up in sales and sales leadership and I still love it, quite honestly, but right now I find myself more motivated by the operational and cultural challenges of running a business like Agfa HealthCare.

This is an old company. We’ve been in business for 150 years and in healthcare since the 1940s. That’s a long and meaningful history because of a commitment to innovation. If you look at the evolution of the company, we’ve been able to maintain a market-leading position in our two primary businesses of medical imaging IT and x-ray technologies.

How is imaging changing with the push for value-based care and care coordination?

When people think imaging, I suppose they think traditional radiology and cardiology, the birthplace of medical imaging. Our more successful customers are taking advantage of the power of medical imaging throughout the hospital and beyond the four walls of that hospital. We’ve got customers who are using it, distributing it, or viewing in upwards of 35 and 40 different departments, so it has gone beyond radiology and cardiology.

Medical imaging in that expanded use can have a tremendous impact on patient care. No medical record is complete without clinical data, medical imaging data, and of course content document management data. There’s still a lot of paper in hospitals these days. We believe we’re completing the medical record and making it better for patients who are our ultimate customers or consumers of healthcare, making it easier for our hospital customers to deliver care more efficiently and effectively for our consumers.

Imaging contains the image itself as well as any clinical commentary or analysis that has been added. What’s the best value case for each of those?

It’s evolving. It’s getting there, but we’ve still got a way to go. If you look over the last decade at the importance of the electronic medical record and the Affordable Care Act’s impact on adoption, it did leave a gap in completing that story. It is really over the last couple of years that we’re seeing the adoption of enterprise imaging and the expansion and the use of that.

If you’re a patient, if you’re a care provider, if you’re a referring physician, to have that picture go along with the words is really completing the story of the patient. It’s not until you have that full story we believe can you make a comprehensive diagnosis and care plan for that patient.

Does imaging have a population health or research component?

Absolutely. Is Agfa HealthCare a population health management primary company? No. Do we participate in that space and are we going to be a key component to an overall solution? Absolutely.

With respect to medical images themselves and the use or data mining of those images, there are use cases where we can look at historic studies. For example, lung nodules, if we’ve got a patient that presents with a lung nodule, a physician may look at that and make a determination — based on the size, based on how long that nodule’s been present — to either act or not to act. To incur that expense and that patient experience or not.

If we can roll forward and have that volume of data or those studies and put together trends, we could use this predictively to make sure we’re making proactive recommendations or not based on like studies that have been stored over time at a particular institution or across the industry itself.

Patients still complain that new providers don’t have access to their previously taken images. Are we making progress on sharing them?

That is the power of our platform. On a single platform, it’s consolidating all of the image data from multiple service lines. It could be from multiple PACS, multiple departments inside the hospital, and outside in a secure manner, which gives access to patients. Lets them see their medical images. It could be providers who are giving the care and it could be the referring physician. Anytime, anywhere. It is absolutely enabling and perpetuating that medical image regardless of proprietary specifics.

How would I as an office-based physician best gain access to a health system’s images of my patient?

Historically you would have CDs. A patient would leave a hospital with a CD, or going way back to the film days, a big manila envelope. What happens to those CDs? They get misplaced or a patient forgets to bring the CD to the referring physician’s office. Then you either lose the time with that physician or that patient doesn’t get the care that they need at the time, it could result in reprinting or populating of that CD.

With the technology that Agfa brings, there is exchange and distribution of that image from the single platform where it was captured. Then there’s viewing capabilities by anybody who participates in that image chain or in that image experience. If I’m a patient or if I’m a referring physician, through the technologies — over and above the original capture of that image — they’re able to distribute and or view that image, taking advantage of eliminating the need for film or CDs.

What is the state and the future state of integrating images with EHRs?

There’s a reason that the big EHR vendors don’t necessarily label themselves as experts in medical imaging. It’s difficult, it’s complex, it’s vast, and it’s a critical component of the legal medical record.

To put our industry in a position where we can take advantage of a single EHR integration across departments, regardless of where they exist, and to connect that to the patient’s medical records so as to bring it all together, it’s only going to make it a better experience, more efficient, more economical. There’s going to be lower total cost of ownership with respect to the number of disparate systems that you’re having to maintain. It will facilitate the flow in the way the physician wants to experience it or the way the patient wants to experience it. That is what is driving our development efforts and our integration efforts when it comes to playing with some of the larger EHR vendors in North America.

What are people doing with VNAs beyond just storing DICOM images?

I come from the EMR industry with 10 years at McKesson. The parallel between then, the clinical data repository and the Web portal or physician portal viewer, and today’s VNA and the viewer … much of our competition had gotten a head start on that and we let them run. We gave them that head start because we took a more holistic approach to this. We wanted to deliver a full solution that was not simply about a repository and a viewer, but it was about the capture and the distribution of those DICOM images to all caregivers, patients, and referring physicians across all settings of care. We took a little different approach to it.

There is non-DICOM imaging. It is a major component. Agfa Healthcare has a very successfully deployed an enterprise content management system in our European customer base that we are now considering bringing to North America. Not for the benefit of competing nose-to-nose with those existing vendors in that space, but actually taking the enterprise imaging and document management and bringing them together so that one and one becomes three for our customers. We’re able to bring that workflow. We’re able to bring the advantages of having non-DICOM and DICOM images managed by the same vendor and distributed into the workflow of our care providers and other caregivers in a seamless and efficient way. That is something that we’re investigating quite seriously.

It’s been said that no doctor wants a physician portal. Is it a challenge to go beyond pull-type systems to pushing the new information automatically to the systems in which the provider works all day?

It can be. You’re right — patient and physician portals have been in the industry for 15 to 20 years. Agfa’s approach to this functionality is different, where we are utilizing it in a use case scenario or problem-solving opportunities as it relates to our enterprise imaging application. We’ve got a portal solution that we are marketing to make it easier for our patients to experience the care provided by their community hospital or their integrated delivery network. We are doing it on a problem-solving approach.

Rather than say we’ve got a physician portal or a patient portal that is to replace the legacy systems that are out there, we are integrating it deeply into our solution so it becomes a seamless component to that experience, whether you’re a care provider or a patient. You’re right — pushing that information is more important than pulling that information. We’re making sure that, much like we have in the development of our core solutions, the information is where they need it and it’s in the hands of the right person on that image chain at the right time.

Where do you see the future of imaging as it relates to medical informatics?

The opportunity is only going to get bigger. The opportunity is for those vendors who are in this for the right reasons, with the right vision, and not trying to isolate themselves but rather to avail themselves to the greater good, which our ultimate patient, the ultimate consumer. Those that recognize interoperability is a must and that we are not going to be all things for all people.

But I absolutely firmly believe that medical imaging, enterprise imaging in the manner that we’re espousing, is going to be a critical component in our delivery of healthcare, whether you look at the development of population health solutions and the participation in HIEs or if you look at a small community hospital. They are the HIE, if you think about it. In their community, they’re everything to their patients.

It’s how we choose to work with our customers to align to their outcomes. That’s going to make the difference and those are the vendors that are going to survive, those vendors that are driving the patient outcomes, driving our customers’ outcomes, and letting those outcomes drive our R&D. That will drive our direction as we look to develop our place in the marketplace.

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November 14, 2016 Interviews No Comments

HIStalk Interviews Stu Randle, CEO, Ivenix

October 26, 2016 Interviews No Comments

Stuart A. “Stu” Randle is president and CEO of Ivenix of Amesbury, MA.

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Tell me about yourself and the company.

I’ve been in the med tech business for 25-ish years, a lot of that with Baxter in the early years. I’ve done three small companies, this being the third one. Ivenix is focused on transforming IV infusion therapy with a fundamentally different pumping technology, IT architecture, and interoperability that we think is unmatched in the marketplace.

One of the challenges in the marketplace today is that most of the pumps that are out there have a fundamental operating platform that’s 10-plus years old. We started with a blank sheet of paper to try to move us into the iPhone era. As an example, we provide infusion information on mobile devices and desktops so the nurses have the ability to understand what’s going on with the infusion when they’re not at the bedside. That obviously helps from a nurse workflow standpoint and also significantly helps for the patient because the nurses don’t need to be there for them to know what’s happening with that infusion.

The early generation smart pumps had a lot of programming capability, but always seemed to struggle with network connectivity and library updates. How hard is it to turn that 10-year-old technology into a true connected IT device?

Really hard. Think about the pumps in the marketplace today as your desktop computer from 10 years ago. If you want that desktop computer from 10 years ago to work like an iPhone does today with apps, mobile, cybersecurity, and everything else, that’s hard to do.

Where we think we are very different is that we started with a clean sheet of paper, understanding all the issues and developing a different pumping technology, but much more so a fundamentally different IT architecture that is relevant today and not a decade old.

What are the challenges in creating a user interface that works for nurses and that FDA will approve?

The FDA has pretty specific guidelines and requirements. You have to do testing. We’ve had nurses in every couple of months for a few years now to work on the user interface.

Again, the fundamental difference with our user interface is that it’s much more like an iPhone. It’s menu driven. It’s touchscreen, as opposed to the products out there today that are mostly buttons and knobs. We have a pretty big screen so the nurse can see the infusion information standing at the door to the hospital room as opposed to standing right next to the device.

What safeguards exist to help prevent nurse programming mistakes?

The more you can program in to alleviate those and make it very difficult for the nurse to make an error, the better you’re doing. We have a number of things that help in that regard. For all the drugs, there are guidelines that can be set up by the hospital. What’s the recommended range? We notify the nurse if the programming is outside the range but still acceptable. Then there are limits beyond that where the pharmacists have said, "Don’t do that." That’s one area where we put those guidelines in place.

Our pumps also know if there are other pumps connected to that same patient. You can’t give the same patient the same drug from two different pumps. We know that what’s going on with that patient from all of the pumps connected to them. We eliminate that. We know if on one of our pumps you can deliver through two inlets, if you’re going to deliver two drugs that are incompatible with each other, we’ll notify you of that when you try to program it and say, "These drugs are incompatible. You can’t do it."

We’ve built in a number of things, partially with the work of the hospital pharmacists and their drug library, as well as the guidelines and architecture so that you can’t do things that we know are going to be harmful to the patient.

What’s the ideal state of having a smart infusion device talking to an EHR system?

We worked at HIMSS last year with one of the vendors on doing that. The more information you can deliver directly from the infusion into the EMR without any integration engine in between, the better. We are working with those guys. We can provide all that information and data and make it smooth and seamless.

Likewise, we can download orders from the hospital pharmacy directly to the pump itself. The nurse is there to verify that, yes, this is the order that we have for this patient. This is the right dosage. Pretty much hit “start” and we can go. We try to make it as seamless as possible and integrate into the entire EMR.

We’ve heard from a number of the EMR vendors as well as hospital executives that one of their primary product areas with the greatest frustration and the lack of interoperability today is infusion pumps. We think with the architecture we’ve put in place that we’re going to solve that issue.

What improvements have been made in pump alarms that just make noise until someone shuts them off?

We’ve done a couple of things to reduce them as well as to eliminate the aggravation. One of the biggest areas of alarms is air in line. We have an air eliminating filter, so we can eliminate the need for that alarm to even go off because we eliminate the problem. If the patient bends their arm and kinks it, it will give an occlusion alarm, but if the patient moves that arm again, that alarm will stop and the infusion will continue.

What quality improvement opportunities do hospitals have in using the information the system generates?

They can look at reduction in medication errors. They can look at nurse efficiency and workflow efficiency. All of our pump data is available to the biomed department or the engineering department, so the pumps know when they need to be maintained as opposed to a regularly scheduled out-of-service process. The infusion data can increase charge capture.

We are working with the hospitals to say, we have this wealth of data. How would you like to receive that? How would you like to utilize it?

What are the IT implications of implementing your system?

We work with the pharmacy on uploading the drug library, which we will do as part of the service of the installation. We’re very different from the other guys in that we do everything wirelessly. If there are cybersecurity patches, if there are software upgrades, if there are other items like that, we can do that wirelessly.

At HIMSS, I spoke to someone who was responsible at his institution for a fleet of 18,000 pumps. They had a software upgrade. For them to implement that software upgrade, they had to take each of these 18,000 pumps out of service. We do it all wirelessly, just like when you get a new app on your iPhone. Things like that are huge improvements in productivity and also certainly help on the IT side.

How to you address theoretical security risks?

We started with this clean sheet of paper. Our software guys came from other companies where they were on the receiving end of this information and know the architecture. We architected it with encryption and security similar to the banking system. We always envisioned that we would be going to the home and other areas of care. Cybersecurity was always at the forefront of our thinking in terms of safety because we want to go well beyond the hospital to the entirety of the hospital enterprise or system enterprise. We built it in on early on. We feel quite confident of our security today.

Your competitors are mostly big companies that earn exclusive contracts to provide all the infusion technology for a given health system. How do you see the company changing in the next several years?

As you noted, it’s pretty much an oligopoly today in the US, but everyone’s using technology that is analogous to a 10-year-old desktop. We’re bringing something entirely new to the market. We think that disruption and the opportunity to better integrate with the IT systems within the hospital and across the integrated delivery network or whatever their system is provides us a distinct advantage. We think it is something entirely new and different. We’re pretty optimistic about the reception we’ll receive from the US hospital market.

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October 26, 2016 Interviews No Comments

HIStalk Interviews Michael Poling, SVP/GM, Infor Healthcare

October 3, 2016 Interviews No Comments

Mike Poling is SVP/GM of healthcare for Infor of New York, NY.

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Tell me about yourself and the company.

I’m general manager of healthcare at Infor. We’re a $3 billion software company. Healthcare is about $500 million of that. I came from Lawson Software and was previously at Siemens. My entire career has been in the healthcare IT industry.

As a vendor of an integration solution, what are the opportunities and challenges in an era where everybody wants interoperability?

In the world of acute care consolidation as well as extending care outside the walls of a hospital, data itself and the integration of data becomes mission critical in terms of analyzing patient outcomes married to cost. Everybody wants to understand what their cost is relative to delivering care as well as the satisfaction ratings that are wrapped around it. Data becomes the center of importance.

Does a new level of sophistication exist where health systems are aware of the incremental cost involved with delivering a particular service or a product?

Yes. There’s a need for healthcare to report on lines of business — both in terms of profitability, revenue as well as cost — because of where the industry is in terms of the switch from fee-for-service to more of a bundled fee for delivering care. It’s mission critical for my customers to understand where they’re making money and where they’re not. Line-of-business reporting has become mission critical for them.

What are the staffing, recruiting, and productivity challenges that health systems are dealing with given that a high percentage of their cost involves labor?

Going back to what I said before around the lines of business, you want to make sure that you’re focusing the right talent and the right job to perform the right service. That, married along with where a hospital can continue to remain profitable, is very important. It takes certain skills. If you take it to a specialty hospital, like a children’s hospital as an example, nurses and doctors who deal with children have a certain skill set, a certain mental approach, and a certain soft skill. That goes across the board, depending on what type of care that you’re delivering.

Specializing and understanding what certain behaviors are relative to delivering care and making sure that since 60 to 70 percent of the hospital’s expenses are related to labor, you want to make sure that you’re hiring the right people, that you’re onboarding them, that you’re keeping them for a long period of time to reduce those expenses.

Is the idea of clinical staffing based on patient acuity still controversial?

The industry is still hanging on to the idea. I would say that nobody’s mastered that. Having the right person at the right bedside with the right supplies and with the right skill, but also then maximizing your workforce productivity — that’s still nirvana or utopia.

There are products in the market that help with that, but getting to the point where you enter things in like seasonality as well as population health and population management to predict hospital inpatient stays as well as outpatient care delivery needs — that’s where we still need some assistance in the healthcare industry.

Floating nurses to cover other areas based on workload needs appeared to worsen patient outcomes because they weren’t as familiar with the workflows and relationships in those areas. Have hospitals improved that situation to give them more workforce flexibility?

It’s the reason that you’re seeing the world of the minute clinics and delivering care in mall settings as well as in the retail space. There’s a need to push those types of resources out to the population. That trend is going to continue, where you have more skilled labor outside of the acute care setting and putting them in those remote settings.

There’s a balance to that as well. You need to have people that continue to deliver family practice medicine, but specialize in some of the things that you’re talking about. The US is going to continue to have the need to push services out into the population. Balancing that with the costs that we’ve been talking about is the real challenge.

Do hospitals have the necessary expertise to run freestanding EDs, urgent care clinics, and population health management programs?

That’s a very good question. What I see is that there are more executives who are coming outside of healthcare into the healthcare world, as well as more physicians who are getting into IT-related services. The reason for that is that if you come from a manufacturing or retail world and understand things like distribution, workforce management, and the distribution channel, that’s different from somebody who has been in healthcare their entire career.

If you layer on top of that the care delivery path aspects that a doctor or nurse understands, that adds that layer of knowledge as well as flow to what needs to be delivered to remote locations that are delivering care.

How do hospitals use technology to help them continue to offer money-losing services by funding them from profitable lines of business?

There’s certainly a technology aspect to what you’re talking about. What I see is that there are more referral networks that are being built through affiliations, through relationships, through of course ownership and consolidation. You make decisions as a hospital what you can and you can’t do. Then you build affiliations around things that you need to deliver.

Labor and delivery is a good example of that. Heart would be another good example of that. If you have somebody who needs critical care related to a heart condition, you want to have an affiliation, a brother or sister hospital that you can send that person to given the time available to do that. I see that as driving the need for technology.

Building the referral network drives the need to then share information between those facilities to get integration. Certainly resource sharing as well as supply sharing. Twenty or 25 percent of a hospital’s expenses are supply related, so you have to make sure you’re maximizing those as well. The technology is needed to accomplish the things I talked about.

Some hospitals choked in the late 1990s and early 2000s  by trying to implement SAP, which was then mostly known as an enterprise resource planning system for manufacturing. What’s the status of ERP in healthcare and how has that evolved from yesterday’s materials management systems?

I laughed when you said SAP. I had a couple of personal friends who left Lawson when I was there to go run the SAP healthcare practice. I know exactly what those challenges were.

What ERP is turning into for healthcare specifically is sitting adjacent to the electronic health record and enabling a healthcare institution to be able to capture the cost components that we’ve been talking about. Analyzing that and looking at lines of business reporting.

ERP has become the need to start to drive the analytic, which we believe starts right with setting up the general ledger and setting up how you’re going to look at the lines of business and then reporting from those. Controlling labor, controlling cost, as well as measuring the cost. ERP in healthcare has become a central strategy to being able to do those things.

The pendulum swung hard to the left to implement EHR systems in the past. It’s now swinging back to the right. Once those EHR systems are implemented, now you need to implement and maximize the other side, which is where an ERP system comes into play.

Do hospitals expect their EHR and ERP vendors to share information bi-directionally?

Absolutely. They’re looking for plug-in integration points. From my side, they want my system to immediately talk to Cerner, Epic, or Allscripts. Give me something that’s going to plug right in where I don’t have to build point-to-point integrations, because we know what integrations need to happen. We know where the data needs to reside and where it needs to get to. That’s what we’re being asked to do and what we’re delivering.

There’s a push for hospitals to implement customer relationship management systems for both business and population health management purposes. How are hospitals addressing that need?

Most of the time when we get into that conversation with a customer, we drop the “C” part of CRM and talk about relationship management, which seems to resonate. Their relationships with their patients …you immediately go there with population management, measuring customer satisfaction or patient satisfaction, making sure that you’re engaging the patient on an ongoing basis. Once they’re discharged, make sure that they’re following their instructions for their medications, those types of things. That relationship that you have with the patient certainly is important.

The other relationships that are important … I talked before about the referral network. The physician referral process and physician referral relationship is extremely important. One physician referring to another physician that’s in the network of the hospital that has built, either through acquisition or through affiliation, this network that they want to continue to feed. The relationships between the physicians become strategic and important as well to making sure that you’re keeping the patients inside of your health network.

We see those two huge needs as relationship management going forward. Of course then you can take the relationship management to the population health to that next step, being able to look at recurring patterns in your population for certain patients and patient outcomes via that relationship management.

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October 3, 2016 Interviews No Comments

HIStalk Interviews Eric Widen, CEO, HBI Solutions

September 21, 2016 Interviews 2 Comments

Eric Widen is co-founder and CEO of HBI Solutions of Palo Alto, CA.

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Tell me about yourself and the company.

I’ve worked in healthcare my entire career. I’ve had an eclectic mix of experience working for consultancies, electronic health record vendors, for myself for a period of time, and for providers. All with a focus on implementing technology to drive improvement, from a health system standpoint and now more so from a population standpoint.

The theme has always been around using data that’s inherent in these systems to help drive performance improvement. We founded the company on that concept of helping health systems and organizations take advantage of data to improve their performance, Specifically to improve population health approaches by leveraging data that’s mostly residing in electronic health records, which have become more ubiquitous over the last 10 or 15 years.

How do you position the company among the many that offer analytics and population health management technology?

Population health, analytics, and even predictive modeling are broad-based terms and topics. Many vendors are saying similar things.

Where we differentiate is that we’re not a platform company. We’re very much a focused solution that we term a precision health solution or precision medicine solution that’s leveraging real-time predictive models that are proprietary intellectual property that we’ve developed. These are our own real-time predictive models that we provide that drive our precision health solution. That’s a niche focus.

We’re technology platform agnostic. We see this as an important piece to identify people at risk for untoward events before those events happen. In real time, meaning leveraging electronic health record data to do that in order to keep people healthy and from creeping up the disease and cost curve over time. That engine that we built can be installed in many different types of platforms. We think it’s an important piece of the puzzle.

Population health includes analytics, care management to take care of the patients, and the interventions that are going to be applied to patients. Our focus is in real time identifying people at risk for poor outcomes before they happen and then identifying the interventions to apply to those patients in order to mitigate the risk from ever happening.

That engine is what we provide. It can be deployed on many different types of platforms, including interoperability system platforms or EMR platforms. Those two examples of interoperability solution vendors and electronic health record vendors also pitch that they do population health. They provide the platform to do that. Very few organizations are providing the specific engine that we provide.

Are providers becoming willing and able to intervene when their patients are flagged as high risk?

What happens on the provider side today is that they’re balancing multiple incentive structures. They’ve dipped their toe in the water. What we’re seeing is 10, maybe 20 percent of the health system’s population is under a new payment mechanism, meaning at risk and/or upside gain for populations. But they’re still balancing the fee-for-service methodology at the same time. These are schizophrenic conversations. Everyone agrees that future is coming and that taking care of patients and keeping them healthy is going to be the new care model going forward, but they’re not there yet.

Organizations are confused about the speed of when that’s going to happen and it freezes decision making a little bit. Organizations are being successful with the experiments in taking care of patients proactively to keep them healthy in order to make financial gain under these new payment mechanisms. Where they can carve out those patient populations and apply these methods, they’ll restructure their care management processes to do that.

They’re really struggling with that decision when and how to do that. We see them doing it well where the incentives are aligned and there is a service component to that to help them rewire their care management processes to think differently about taking care of patients pre-disease or taking them from an at-risk standpoint as opposed to post-disease, which has been the old care model.

Is it an ethical struggle for providers who are beginning to see the value of providing population health management but realize that it could cannibalize their incomes if they do it or everyone, including those for whom they’re being paid fee-for-service?

I don’t think it’s an ethical struggle. It’s a clear problem to solve. It gets back to the acceleration of when are these going to come in full force.

We have clients that have done exactly that. They’ve done such a good job at using our solution to target patients at risk, keep them out of the emergency room, keep them out of the inpatient setting, keep them on the right care programs to mitigate disease progression, whereby they have reduced admissions and volume to their hospital. They’ve had a struggle with that.

What they’ve said is that this is the right thing to do for the patients at the end of the day, to keep them healthy and out of the acute care settings. What they’re looking to do is figure out how to accelerate taking on more incentive-based contracts and risk-based contracts in order to keep this going.

I don’t think it’s unethical. They had upfront conversations about it and they’re trying to figure out strategically how to continue to navigate this process. All of the organizations we’ve talked realize it’s coming and they’re willing to prepare for it. It’s just a matter of speed.

Providers can’t just unilaterally reach out to a high-risk patient and tell them what to do. Is it a marketing challenge as well as a clinical challenge to get patients engaged in this process that’s new to them?

Disengagement from a patient standpoint is a continuous problem for care managers. The ability to engage the non-engageable is a never-ending problem for the care management folks.

What we’re seeing and what we think is important is that the applying the same interventions to the whole population is inefficient. Applying risk stratification information to your patient population allows you to target both resources and the right interventions to the right patients in order to focus. It’s a much more efficient deployment of resources in order to be successful in this game so you’re not wasting time on patients who are otherwise low risk.

The non-engaged patient population, there’s always a sub-cohort of those patients that are always there. It just requires different skills to engage them from a care management standpoint. It’s very much an approach and a methodology that these organizations need to think about to solve that problem.

We will probably look back years from now and see the readmission focus as tactical, with an uncertain impact on outcomes and maybe even on overall cost. Will this push to identify high-risk patients extend further than just keeping them out of the ED and inpatient beds?

I think that’s right. CMS has been thoughtful about their approach for aligning incentives. They’ve gotten better over time for doing this. You see the commercial insurers following CMS’s lead.

The one metric of focusing on readmissions post-discharge, you do have to apply advanced proactive and thoughtful discharge planning to mitigate a patient from coming back, which includes understanding the local and outpatient ambulatory resources that are available in order to mitigate the acute readmission from happening. Even though it was focused on an inpatient metric, the ability to affect that measure required them to think pretty broadly about systems that are potentially external to their four walls to put these programs into place.

I thought it was a good exercise to being able to mitigate that measure or outcome on patient population against a broader portfolio of measures that they’re going to put into place, which is going to inevitably head to capitation 2.0, payment to keep patients otherwise healthy and not using unnecessary resources to stay healthy.

Couldn’t hospitals dig through their EHR data themselves without additional technology? Also, is it enough to use that inpatient data snapshot alone vs. what might have happened to that patient in the 30-day readmission window?

The philosophy is to use any and all available data on the patient in order to understand what’s going to happen in the future. EHR has provided a great, rich resource for that data set. They are real time and they’re clinically based. But you can augment that with claims data, billing data, and things like natural language processing, which is extracting information from the notes and also connecting that to publicly available data from things like the CDC or census information to understand average income levels or average education levels per ZIP code. All the information that is becoming more and more available on patients is very helpful in predicting the future that’s going to happen.

You want as much information as you can possibly get on a patient to predict the future. That includes not just the inpatient data, but the full gamut of inpatient, outpatient. You’ve got public HIEs, which can provide a rich resource if they’re structured correctly in capturing data centrally to have a longitudinal health record across the geographic area. But what you’re seeing health systems do more and more now is deploying more private HIE infrastructure to tap into that ambulatory information that’s extending beyond their four walls and at least setting up agreements with ambulatory providers to capture as much information to provide a comprehensive view on the patient.

Where solutions like what we provide come into play is allowing the machine to do as much as work as possible to help augment clinical cognitive thinking on the patient population. Computers and computer machine learning and so forth can automate a lot of information that a physician and or care manager wouldn’t otherwise be able to do. It can help them augment their clinical education and background in order to take care of patients by providing more information that they otherwise wouldn’t have.

Another component is the ability to integrate into the workflow. Risk information is helpful in providing the content to understand which interventions to apply to mitigate the risk. Automating that into the clinical workflow so that it becomes part and parcel of what a clinician and or care manager is doing on a day-to-day basis is a necessary component in order to not have bifurcated systems and make the workflow as efficient as possible.

What this gets down to is identifying proactively patients at risk with the interventions that apply to that and automating suggested care plans and orders on the patient that a physician or care manager can quickly think through in order to provide the right intervention to the patient.

Where do you see the concept of predictively identifying patients at risk playing out over the next five years?

When we first started this, there weren’t too many players in the game. What we saw mostly in the market were legacy, claims-based risk vendors who were focused on the insurance market or health plan market. What we’re seeing now are more companies like us using clinical information to provide real-time risk stratification information.

Over time, these will become more of a commodity and part and parcel of doing work because it’s necessary for organizations to think this way proactively about their patients and patient population and keep them healthy at home. All the right incentives are aligning to make this a necessary core component of taking care of patients while they’re healthy, while they’re in a pre-disease state, forever escalating up the risk curve.

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September 21, 2016 Interviews 2 Comments

HIStalk Interviews Travis Bond, CEO, CareSync

September 19, 2016 Interviews No Comments

Travis Bond is founder and CEO of CareSync of Tampa, FL.

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Tell me about yourself and the company.

I’m the founder and CEO of CareSync, which is my ninth company. My last company was Bond Technologies, which created one of the very first browser-based EMRs in the world. We had the opportunity to exit to the Eclipsys Corporation back in 2008, I believe.

I put the band back together in 2011 to create CareSync, which is a patient-centered electronic medical record that has a service on the side that basically acts as a record aggregator service. Carbon-based interfaces go out and get records and put them in a usable format that can be later searched, shared, and collaborated on. That all gave way to a business opportunity that CMS created in 2015 for chronic care management. That’s where we are today as one of the industry’s largest providers of chronic care management services under the new code.

Which is the chicken and which is the egg in offering a product that both consumers and their providers use?

It was probably providential in some ways that we cut our teeth on a consumer product. We weren’t bound by Washington, DC regulatory requirements for a product roadmap. What’s really useful for people when they become a clinical patient is they need information and they need resources that help them to shorten the gap between what providers are saying and doing on their behalf and how they can then respond. That product, started in 2013 and known as CareSync Plus, had about a 3 percent conversion rate when we went out and advertised it to people.

It is the CMS product that now gives us the business-to-business product. We act as the vendor on behalf of the provider to offer essentially the same service. The difference — and why we still have a chicken and an egg — is that about 5,000 members a month come onto the CareSync platform as family members. Some of those family members want the same services that CCM provides under CMS for themselves. We really couldn’t sunset a legacy product when there were still people who wanted to be more of an active caregiver or wanted to be more engaged patient.

What is the scope of the CCM business?

CMS has released information only about twice on how many people and how many claims they’ve produced. At last count several months ago, about 300,000-plus have been enrolled in CCM programs since their inception in 2015. From our point of view,  the geography of that number of claims is all 50 states. We have users in 30 states alone. It’s not really because we had any grand master plan, it’s that there is an alignment with many practices that want to try to care for people where they live, work, and play, not just at points or nodes of care.

I think CMS was disappointed that it did not ramp up as quickly because CMS had identified that they were going to pay $10+ billion every year for this program. Theoretically, it created a much bigger total adjustable market per year, $16 billion in 2015 and 2016. That number actually increases to a possible addressable market to $20+ billion because now they’ve given three new codes out to incentivize the market. One is an enrollment code and the other two are to address complex chronic care.

It’s not going away. It was a slow-starting process, but it’s being addressed from many different areas. The inevitability of chronic care management programs throughout healthcare has pretty much been set in stone and will just continue to grow as other new things have been introduced in healthcare over the last several decades, like HMOs and PCMHs and others. This is just another one in the fold that will continue to mature.

If I’m a physician and I think you’re a candidate to participate in CCM, what is your obligation as a patient?

It’s really quite simple. There is the consent process, which CMS wanted to know that there was written confirmation that a patient was elected to participate in something that they were eligible for. In this case, two or more chronic conditions. The chronic conditions, though, were very liberally interpreted by CMS, meaning that they were not going to actually put edits on what a provider thought was a chronically ill condition for the patient. If you look at ICD-9 alone, there are over 4,500 conditions which are marked or flagged chronic in nature.

From a patient’s perspective, it really is how you design the program. Patients need to have access to information, electronically or written, and have access to those that can access that information and are clinically trained or licensed 24/7. It’s more of an access from the vendor or the provider’s perspective. The patient, outside of them consenting to the program, just needs to make themselves available. The program  is designed to give back more time and resources to where patients need it and that’s in the consumption of the treatment plans that various providers are administering to them, a reconciliation of that.

We’ve found that variability of patient engagement is as wide as any that you could imagine. Some just like to be called once a month and talked to. Others will have inbound calls and want to talk extensively about their progress. We have patients that will be a few minutes a month or it could literally be in the several hundred minutes per month. Patient requirements are still low, other than their co-insurance or co-pay responsibilities.

Otherwise, it’s intended to be a service that is aggregating information, creating a comprehensive care plan that the patient can then consume and can be collaborated and administered, and then lastly, creating a health summary that can be provided back to the patient or anyone who is seeing the patient. Overall, patient requirements are still low, but it’s incumbent on the provider to maximize the value to the patient of the program as prescribed under CMS.

How does Medicare verify or monitor that services were provided and not just billed?

In the CMS program, you bill Medicare and they pay based upon whatever edits they can run through a computer system. They don’t verify until they actually audit.

This code is really no different. They’ve said at least initially in the first couple of years that they weren’t going to put edits on their claims, meaning that they weren’t going to necessarily determine whether a chronic condition had met some criteria that Medicare would feel is not chronic enough or chronic in the right way. They’ve left that up to the physicians’ discretion.

What we’ve found is we have hundreds of chronic diseases that are on our lists for the patients who we serve. As you know, there are even several thousand rare diseases that meet the chronic definition. As it stands right now, we’ve not seen any claims denied as it relates to the diagnosis that has been tied to the CPT code 99490.

How did CareSync’s recent $20 million in new funding come about and how has it changed what you do?

We were very fortunate to have a lot of venture capitalists and strategics already having conversations with as it related back to our legacy product, CareSync Plus. Many people felt that there needed to be a connective tissue, if you will, for patients where they’re in the space that we call the dark space, which is where you are when you’re not at an appointment or a hospital setting. This dark space is like trying to navigate between airports without a radar system or air traffic control. The thesis was that surely some entity or some party would benefit if patients were better monitored and/or had the opportunities to help themselves adhere to what was prescribed.

When the code came out, it was the match that lit the fire. We were setting ourselves up with people who thought that there were problems in healthcare that could be solved with a combination of nurses and technology. Having those things in place when the code came about allowed us to execute on closing financing rounds from those players. They have since then recommitted to continuing to fund CaresSync.

We feel that the chronic care management market will continue to grow significantly, especially under the new codes in MACRA. We have 18 months of solid data that shows that providers are getting paid. We’re seeing real tangible benefits for clinical outcomes as well. Nine percent of our patients that come into the system have a severe drug-to-drug interaction that no one knew about. That’s nearly one in 10, which is pretty significant because it’s the severe drug-to-drug interactions that potentially are lethal. Sixty-four percent of our patients avoided a duplicate test because they had the results with them. A provider avoided re-prescribing another test because they felt that they had the results that they needed at the time of care.

There are many things that illustrate the advantages of the program. Those things obviously matriculate back to value when you look at an investment community. The key thing in pairing up investments from the investment community and being an entity in this space is the ability to execute at scale. We have found that it is much easier to have a chronic care management program at 30 nurses than it is 300. There are natural elements of growing and scaling that process and learning a lot of things along the way.

I think that what you’ll see overall in the market is that there will be a continued interest from the investment community in supporting this dark space and the vendors that emerge from this innovation opportunity.

Are you seeing any improvement in the ability and willingness of hospitals to provide patients with their electronic records in whatever form they request?

They’re getting a little bit better, but we’re getting a lot smarter. It’s the combination of the two that has created the net result that we are getting better, faster results from the data.

There has been an implementation of these HIT systems lag, in terms of those professionals who are running these systems even knowing that there are features to share the information. There’s still the HIPAA cloud of death and despair that hangs over all of these institutions. They feel that they need to protect this data, even from those who originated it, like the patient. That becomes primarily an education step. There’s still also a lot of medical-legal sensitivity. Why does a person want their data? Do they think we did something wrong?

That’s still a case-by-case process that we have to go through at CareSync. It’s still far easier for a provider to request information than it is a vendor. A vendor is always suspect. It is slowly changing. I wouldn’t say that we have a marked increase in the amount of freedom of information posture of these institutions that hold large amounts of it, but at least we’re seeing some incremental changes in a direction for the positive.

You were selling EHRs in the heady days. Are you glad you aren’t still in the EHR business?

Yes. [laughs] I am glad that I’m not there. In retrospect, the advent of EMRs bogged down the efficiency of a visit.

Having some medical training acted as the foundation for creating our EMR program and helped me. Technology took away from a lot of the observation skills. A  good portion of medical school training is spent in diagnostics and observations of patients. Those just can’t be done simultaneously while also working through documentation requirements.

Hopefully, programs like chronic care management and other things that try to reintroduce an experience that the patient feels comfortable in talking and sharing information and how that’s captured — I’m hoping that we can blunt some of the negative impacts that EMRs had. But I would say that if I ever had to be reincarnated, I would not go back into building any piece of software for ambulatory healthcare. That was a very painful pioneering pathway to walk.

Do EHR vendors get blamed for too many clicks and too much pointless information collection instead of those parties on the back end who require collecting that information before paying providers?

Yes. I would have to side with the EMR vendors on this one. It’s not their fault. It’s Washington, DC that creates the product road maps for vendors now. It’s not what users want.

Users want a certain amount of clicking so that they can document, recall, and have that information available for the next visit or for other providers. There’s real fundamental and foundational value to EMRs. But the direction they’ve taken in terms of usability, unfortunately, was hijacked by those that were writing the checks for them in the first place. Under ARRA,  the government was paying for them, but as a result of them paying for them, they were able to create what they were going to be under Meaningful Use.

There’s always a balance here. We are better off that we now have EMRs, undeniably. You’re in a far better place in being able to record this information a way that we can learn it more rapidly off the science of healthcare and treating those that have disease.

The disadvantage is that we’ve made the billing system on par with the IRS tax code. We’ve made it so complicated that it’s very difficult to do an effective visit with the necessary amount of documentation in a way that demonstrates what took place such that it could be reimbursed on par for what happened. I’m hoping that we’ll eventually get through this, but I’m worried about the overall physician dissatisfaction with their job as we go through this lonely period of transition.

Are consumers really gaining power, demanding their data, and becoming involved as participants in their own care or are we just wishfully thinking that was the case?

I think it’s slowly happening. The best chance that we have in terms of developing technologies for patients is that patients are becoming more consumer aware. That to me is probably the biggest weapon that we have. The patient is probably the greatest sleeping giant in all of healthcare. When you go through Uber or a good banking scenario or a good restaurant experience, you understand how brands compete for your business, your attention, and the right to serve you. They see that as a privilege. That’s how good businesses become great businesses.

Healthcare has had the patient lag, where they’ve been more passive and they’ve not really felt like they’re in an empowered position. I think a lot of things will start to accumulate to hit a tipping point where the patient will be more in a position of a consumer. When that light bulb goes off, the technology that they’re experiencing healthcare in needs to be more on par with other things that they experience in their lives.

The biggest advantage to the payer, the provider, and the patient is that when you look at where healthcare falls down, it doesn’t fall down in a science problem. It falls down in to an adherence and data-sharing problem. It’s not like we need better cures — we just really need to implement more effectively the ones we’ve already discovered.

Where do you see the company and the industry in the next 5-10 years?

We’ll be making more decisions in real time. Things like IBM Watson and other types of analytics that will be under the hood … we’ll  see like a TurboTax for health. These things have happened, so you need to do these things.

The problem with healthcare that we’re going to finally get our hands around over the next 10 years is, how do I go do those things? If somebody tells me to get an MRI, who’s going to do that for me? Innovation is going to start to fill in this last mile of putting the things that need to get done to actually getting done and being tracked. That will start to figure its way out over the next 10 years, principally because it’s being funded against something that is challenging our economy, where 86 percent of the dollars are being spent out there to manage chronic disease. If we don’t get our hands around it, we will end up breaking both the legs of the US economy.

What will change is that vendors, payers, and providers will figure out how to play nicely with the patient who ultimately is writing a big part of the check, whether in taxes or insurance premiums. They will start to find an experience to where they’re now more engaged. Not in vendor classic term of engaged, but making them a more efficient component of the healthcare equation.

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September 19, 2016 Interviews No Comments

HIStalk Interviews Jeff Zucker, CEO, MyDirectives

September 7, 2016 Interviews No Comments

Jeff Zucker is CEO and co-founder of MyDirectives of Richardson, TX.

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Tell me about yourself and the company.

The company is formally known as ADVault. The AD stands for advance directive. We are singularly focused on the world of digital, emergency critical and advance care planning.

We started in 2007 and stayed in stealth mode for about five and a half years, doing a lot of research, development, and pilot testing inside hospitals and community centers and with off-the-street consumers to zero in on this fundamental challenge that’s existed for over 40 years – the desire for everyone to have an advance care plan when they need them and where doctors can find them.

We often put a lot of pressure on a very tense situation in emergency rooms by trying to get patients to create plans when it’s a little too late. That creates additional stress and strain on the patient, family, and care team that’s trying to serve them. We’re focused on giving consumers confidence that they can digitize their voice and have their advance care plan heard anywhere in the world, at any time.

While the healthcare world talks about patient-centered care, we say consumer-centered care because none of us really know when we’re going to become a patient. We want to live with confidence that, if and when we become a patient, our voice and plan can be found. That the medical teams will have some insight into our preferences, values, and care goals, and that that can contribute to a better medical experience that will value and honor the wishes of the consumer.

Our consumer-facing platform, MyDirectives.com, went live in 2012 and now has users in all 50 states and in over 30 countries just through word of mouth, the social media tree, and the health insurance and hospital ecosystem partners that have jumped on board since we started.

We went live a year ago with MyDirectives mobile, and that’s exclusively with the folks at Apple. We felt confident in the stability and the consistency of the Apple platform, and the fact that Apple let us give consumers confidence that, for example, in a cell phone environment, even if their phone was locked, they have the option to put some key information about their emergency care plan in front of the lock screen on their phone. Paramedics and ER doctors can push a button, communicate with your legal healthcare agents, and get access to your care plan. We have been very pleased with the early reaction from consumers to MyDirectives mobile.

How else have you marketed the service?

Our marketing is broad-based and multi-faceted. There’s no one way to communicate with every consumer, so we have to rely on consumers talking to other consumers. We have to rely on doctors and nurses. We use the hospital administrative ecosystem. We rely on health insurance plans to make it clear that the creation of an emergency critical advance care plan is a great way for the plan to help their beneficiaries’ voices be heard if there’s an emergency. Health plans are usually contacted by hospitals for insurance verification and it’s a great opportunity for the health plan to say, “Hey, Jeff has a plan. We suggest you go find it and use it.”

We have to bring in all the stakeholders in order to make a big change. Our view is that if this were an easy solution, it would have been done already. The problem is a 40-year-old problem. The first living will was created in 1969 and it’s been a social problem ever since. Because it’s been a problem for such a long time, it can’t be solved overnight. Our view is that we need all these stakeholders to spread the word. It’s the payers, the providers, the consumers themselves, and forward-thinking technology companies like Apple that are finding new ways to normalize a concept. We are very excited by the reaction, but recognize we have a long way to go.

How many users do you have?

The easy answer is we don’t have enough. There are 190 million people in America over the age of 18 and we want every one of them to have a plan and, more importantly, live with confidence that they won’t be a stranger if they have an accident sometime, somewhere. None of us know when we might have an accident, or where that accident will occur, and so it’s a very logical concept to say, “Responsible adults plan.” I don’t think when we went live that we expected the social tree to extend around the world as quickly as it did. We’ve tracked it and see friends and family signing up across the globe. The organic growth has been a great way for us to have a real world focus group, if you will.

How has the federal push towards greater patient engagement helped?

It’s an exciting time to be in the digital health space. We’re at the convergence of a consumer-driven digital world and a healthcare public policy world that’s forced into reform and innovation. We’re at the intersection of the two with a very important voice, the voice of the consumer.

Regardless of the administration in power, I think all of our elected leaders and the administration that supports them have realized that the more meaningful the healthcare experience, the better the outcome. The government has created some ways, some of them better than others, to try to encourage a very slow-moving industry to adopt innovative healthcare technology much more swiftly.

The federal government’s been great at pushing that. As with most things, the government responds to advances in the private sector, and then the private sector responds to advances in the legislative world. The combination, the iterative parallel processing of the two, is incredibly important and we’re very excited about what we’re seeing in 2016 and what we hope to see in the next few years. The Meaningful Use rules, specifically, have been very good at focusing attention and opening people’s minds to the fact that there might be a better way to do something.

How have providers reacted?

The providers that we have talked to, as you would expect, fall along a continuum. No one hospital moves in lockstep. They’re made up of great people with varied backgrounds. Some of them adopt innovation faster than others and so every organization has a challenge to move at a pace. The fact is that, because this is the only thing that we do as a company, we are crystal clear and incredibly focused on some very simple concepts. Every consumer deserves to live with confidence they can have their voice heard if they have an emergency, and most people don’t have a problem with that statement.

If you don’t have a problem with that statement, then the question becomes, how do you go about giving every consumer confidence that in your particular hospital, or the 15 million beneficiaries in your particular health insurance plan, or the 300,000 employees at your company that have self-funded insurance, how does your population live with confidence that they can get their voice heard?

We use technology to solve that problem. We don’t go into a room and force technology on people and say take it or leave it. We go into a room and explain that we have this human interest goal to enable people to live with confidence that they won’t be a stranger, to get rid of that fear that somehow they’re going to get sucked into a system and someone else is going to make decisions for them and they’re going to lose control in an emergency. We know that the number of people that are admitted into hospitals that have a degree of impairment in decision-making capabilities is significant. The inability to communicate or understand creates a situation where mistakes can be made, confusion can be had, and people aren’t on the same page. We know that’s not efficient. It’s also just not great outcomes.

How does your technology integrate with EHRs?

We have a variety of different integration protocols that a hospital can use to touch our database to find the digital care plan a person may have created in advance. If the person has created it, we digitally send a secure link that is populated into the EHR for that hospital.

There are a variety of integration paths that conform to global standards that hospitals can choose from. We don’t tell them what to do, obviously. We are ubiquitous. We don’t really care what EHR platform they’re on and we don’t care which integration method they use. We’re very intently focused in making sure that we don’t burden the EHR platforms. They’ve got way too many things to do as it is, so we take on that work for ourselves. We are the only MU-certified advance care planning module certified to be in an EHR.

Our singular goal is that hospitals have access to the plans created by consumers and that they open them, access them, and use them in a way that respects the preferences, values, and care goals of that consumer. If the person doesn’t have an advance care plan, then we offer hospitals the opportunity to use our system to help consumers create them. Instead of the labor-intensive process and the costly process of counseling and advising people on site in a stressful situation, we can email them or text them a link and they can create it at home. One of our advisors, former Senate majority leader Bill Frist, MD — who as a cardiologist has seen lots of trauma around the world — perhaps put it best when he said, “These issues are kitchen table issues more than they’re operating table issues.”

How does your technology stand up against the typical complaint about advance directives; i.e. that nobody in the hospital knows about them and the family doesn’t know where they’re kept?

Those complaints are real. The research on advance directives and the problems with advance directives have been very well documented and they’re multi-faceted. We’re very proud of the fact that the HIS world and the digital technology world has, in the case of emergency critical and advance care planning, allowed us to bring a solution to market that’s not just the digitization of a paper form. So much of the early wave of the Internet was, let’s just cut down the bricks and mortar and do online the stuff that we did and we’ll scale it faster. That wasn’t enough for us. The entire experience needed to be recreated. The entire context in which you asked it needed to be recreated. Our solution has innovation in not just technology, not just the clinical experience, not just in marketing, not just in the family experience, but in all those areas.

We recognize that people in the paper-based world have challenges with paper-based documents. We encourage them to try the digital experience, and if they think their paper-based document is better, keep it. We want everyone to live with confidence that their voice can be heard, so we’re thrilled if you’ve got a paper-based document that you love and can be easily accessed. We’ll even help you. You can attach it to a digital account in our system and we’ll do our best to help get that into the hands of the hospital if they need it.

We encourage you to try to answer our questions and personalize it with some video messages. It will help others know that it’s you that did it, that you were in your right mind and you weren’t under stress. That you were clearly acknowledging that these were your preferences, values, and goals of care, and these are the people that you want to speak for you. The digital world gives us time- and date-stamping opportunities and markers so that there’s no question of when you made your wishes known. It’s a much more clear and convincing process.

What will the next five years hold for the company?

In the near future, our strategy continues to be focused and simple — to make sure the technology we’ve already deployed is safe and secure, meeting or exceeding the expectations we’ve put on our hospital and consumer partners. We’re trying to raise the bar even more and excite the consumer marketplace with even more fun features that will give them the confidence that their emergency critical advance care plan is a thorough and accurate reflection of their preferences, values, and goals.

We work very hard to add hospitals and do that in conjunction with the HIEs, ACOs, and EHR platforms that serve them. We are aggressively working to integrate into the healthcare system so that providers can pull the plan if the consumer can’t push it.

With all of the innovation that’s happened in the last few years in healthcare as a whole, and the phenomenal success that cloud computing has brought to innovation in healthcare, it’s amazing to me to even start to think about what healthcare will look like three to five years from now. The cloud, for example, was around in a lot of industries before it hit healthcare. We’ve been at the forefront of the effort to try to push comfort in healthcare with cloud technology, especially with regard to its safety and security. There’s got to be efficacy around the information and the data that we share, and complete transparency to the consumer so that they know they’re in charge of their plan.

It’s important for us that the cloud continue to succeed and grow, and help normalize behavior in healthcare so that we don’t go through the expensive process of siloing data, replicating in hundreds of places the same information, which creates versioning problems, unnecessary paperwork and regulations, and wastes the time of doctors and nurses. We’re trying to make things easier and if we continue to focus on the fact that what we are doing helps ensure that a consumer’s voice can be heard if they have an emergency, then everything else becomes pretty clear.

Do you have any final thoughts?

We continue to challenge the leaders in healthcare that use the phrase “patient -entered healthcare” to back it up with the rules, regulations, policies, procedures, and workflows that reinforce that. It is fundamentally important that we practice what we preach. If we truly care about the voice of the consumer, then we have to do everything we possibly can to make sure that we’re hearing that voice, that we’re asking people to digitize that voice well in advance, because obviously the most chaotic part of the healthcare continuum is when you’re in an emergency situation where you probably can’t communicate.

Have we done anything in society to make sure that the Terri Schiavo situation can’t happen again? We don’t think society has done enough to make sure that experience doesn’t happen again. We can ensure that experience can’t happen again if we have confidence that every decision-making adult has created a plan, shared it, updated it, and verified it. We trust the medical community to take that information and create the treatment plans and protocols to meet those goals. The Terri Schiavo situation was terrible for everyone involved, but the only person who never had an opinion they could express about it was Terri herself. We’re not so focused on what her outcome was or wasn’t. We’re focused on the fact that she didn’t get her voice heard and it was her life.

Whether you have a car accident and you’re in the hospital for a couple of days and just want to go home sooner, or you’re in a chronic situation, or you’ve been recently diagnosed with something that’s incredibly serious, or you have an accident … we should not live in fear that somehow we’re going to lose control of our care.

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September 7, 2016 Interviews No Comments

HIStalk Interviews Hank Jones, III, Technology Lawyer

August 29, 2016 Interviews No Comments

Henry W. “Hank” Jones, III is an attorney in private practice and owner of Intersect Tech. Consulting of Houston, TX.

Tell me about yourself and your firm.

I’m a 36-year lawyer in information technology who works as a midwife, birthing transactions and products, usually software or e-commerce. I’ve been in six companies, full-time on the exec team of three in blended roles doing firefighting, utility infielder multi-department tasks, sales, and product design. Coming from an intellectual property background, then doing more and more in healthcare over the 36 years.

We first connected from your comments about market research firms. What do you think about their methodologies and potential conflicts of interest?

Too many customers of IT in every domain, medical or otherwise, are unfortunately naïve that market research is both necessary and insufficient, at least for significant transactions, for multiple reasons. Number one, their methodologies and, therefore and their goals and missions are limited. Number two, there are necessary data, if you’re trying to be safe and excellent and surviving on transactions for a long time, they’re really beyond the market research companies’ skills or traditional efforts. In particular, failure analysis, customer disputes, litigation, and government regulatory filings.

The occasional project leader, IT manager, sourcing "professional," or even worse, healthcare professionals venturing into an IT transaction for the first time, don’t know what they don’t know. Unknown unknowns can be mission critical in choosing what the scope of the transaction should be, how you do the selection exercise, and what negotiating plan or terms and conditions you need. The market research firms vary among themselves significantly on their skill, their processes, and how they get paid. Even then, to do any kind of medium- or large-sized transaction, it’s not enough.

How common is it that companies have legal skeletons in their closets that prospects should know about?

Actual lawsuits are intermittent, but necessary market knowledge. The real question is, what’s the risk profile for the individual transaction and proposed solution? Which involves, number one, looking at other competing vendors’ track records. Number two, disputes that never got to litigation, which always outweigh the quantity that actually get to litigation. Number three, arbitration and mediation. Most stuff never goes to court. Number four, the latest move to automation with the stimulus money, etc.

Many IT customers don’t understand that there’ve been massive sea changes in how the technologies get built upstream and under the hood. They don’t know that every deliverable is a hybrid with many components from many owners. Many don’t know that a lot of what gets delivered was designed using tools and languages that come from third-, fourth-, fifth-tier removed vendor who built good stuff, but it may or may not be available long term. It may or may not have been customized to a significant degree. Further, there’s open source in everything now. Not only in testing activity, but actually in the deliverable.

Too many customers are using 1980s and 1990s assumptions that were then valid regarding software development and content that are archaic and therefore somewhat dangerous now. You wouldn’t use old virus scanning software on your PC for your house to know what’s on the inside. Similarly, the procurement processes and the project plans, negotiation skills, the contract provisions and exhibits that healthcare providers want now should reflect modern, appropriate technology norms, which have changed in the last five or 10 years.

How often do company executives or founders get into legal disputes with their boards or investors?

It depends on the size and age of the company. It’s very common to have a founder displaced after taking an additional round of investment. It’s common to have management teams nudged out, and often financially rewarded for it, after a merger as opposed to an initial venture cap round. It’s even more common in software now.

A third factor that’s newer is the large software-only private equity firms, which have a ton of gunpowder. There’s three or four or five of them that only do software company acquisitions and radical overhauling. They take best practices with an elite specialist consultant team and then do mash-ups. We’re seeing that with the McKesson and e-MDs products getting smooshed together on an ambulatory level, for example. 

In Austin, where I just moved from, there’s a PE company with $16 billion who are doing 20 or 30 transactions a year. Many of them are mid-sized companies, but including some whales like Misys out of London, the deal they did a while ago. Greenway got taken private, so we don’t know their financial disclosures any more.

Everyone should assume that the vendor isn’t who it will be at the end of the expected useful duration of a product. My metaphor is that you and your significant other go out for dinner and a movie and the babysitter has outsourced and subcontracted by the time you come back. Somebody else is watching over your kids.

Is it fair for publications to sensationalize the details about a lawsuit that’s just been filed even though they have only one side of the story at that point?

There’s a problem of inadequate business journalism. There are tons of interesting action items for HIT managers in those 960 Epic-Tata pleadings, but it takes a lot of effort, and frankly, domain expertise, to sift and parse and differentiate what’s normal or not in the legal environment. The splash — yellow journalism would be the technical term — is a problem, but I would say the larger problem is inadequate follow-up and inadequate domain translation. There’s another problem too, which is that things get sealed, although I’ve had some success over the last couple of negotiations with judges later having them unseal some things, one of which was a medical software OEM deal.

What are your thoughts about Epic, Cerner, and other companies that make their employees agree to arbitration rather than labor lawsuits as a condition of ongoing employment?

I’m not a labor lawyer, so I don’t think my comments are that useful. It’s clear that in all parts of US industry, arbitration has been a mega-trend. There’s been push-back in every industry of it being, in some contexts, suppressive and unrealistic.

Real business people and lawyers, however — back on health transactions and other IT transactions in every industry — know that a careful scalpel in contracting, meaning a sharp pen, is a useful tool because what you want is to see prevention processes, governance clarifications, and then dispute-handling processes. The IT outsourcing, multi-year contracts have for years contained customized processes to deal with disputes. Over a period of time, priorities, technology, and the leadership economics are going to shift somewhat.

What people should be doing — and a few smart, creative ones do, but most don’t — is port the transactional tools, the terms, the rules of a contractual relationship, from outsourcing into pure software licensing, on the argument that the software’s going to change, ownership may change, the features are going to change, the security specs are going to change. Why not treat software not as a physical product, but as an evolving thing that it realistically is? Particularly in healthcare where you’ve got changing regulations, security specs, and patches that are more important from the privacy stuff. ADR should be for us in HIT a detailed, customized, thoughtful exhibit in every contract, rather than a two-sentence paragraph that nobody looks at. That’s like ignoring anesthesia in a prep for surgery.

Are patent trolls a big problem in health IT?

Yes. There’s lots of economics, there’s studies on that. The America Invents Act did not solve it. The Eastern District of Texas is still a whorehouse. Not La Grange, where the film with Burt Reynolds and Dolly Parton came from. The judges went to the Dallas bar and recruited the work. There’s not yet a legislative fix. It’s a problem that’s broader, although most visible in technology. A lot of people have worked on that. 

I used to be vice-president of intellectual property development for a $3.5 billion revenue per year company. I’m not really a patent specialist, but I know and work intermittently with people who really are deep in this. It’s still a problem that in healthcare is inadequately understood by customers who don’t know that a shotgun, financially speaking, could be placed to the head of their supplier. In particular, do the hospitals require due diligence by their people and then contractual warranties and insurance purchasing by providers, because patent expenses and threats to their vendors upstream from these third parties are a realistic business concern. It’s not even on the checklist.

A big HIT transaction is like a major surgery. A pacemaker installation, if you want to be metaphorical about it. Have they worked up the patent risk and risk mitigation scenario of each prospective vendor and worked that into their spreadsheet or their evaluation? Some vendors are, and some vendors aren’t, holding their own tools, munitions, and ammo in terms of patents and patent licenses or membership in patent-sharing defense arrangements. There’s a publicly traded company that all it does is provide a shared defense. That tells you that the need is that large, that people could commercialize this reactive requirement.

Do you have any final thoughts?

My hunch — and my possible book, as I look at expanding that 3,000-word article about avoiding health software heart attacks — is whether the industry has a problem with assigning, in effect, pre-med students to do neurosurgery. The observation by many HIT specialists is that a lot of providers only plan and then procure their solutions intermittently. Therefore, they attempt to negotiate against vendors who are professional and have a different set of objectives.

I had a software manager at a very large academic institution come to me and say, "Please help us. My sourcing people know sutures and Band-Aids, but not medium- or large-scale software transactions." It’s a minority of transactions that get done well, resulting in HIT organizations having operational health risks that don’t happen in other industries.

There’s a majority view that’s whispered or shared over drinks that because so many healthcare organizations are relatively new at automating, they have the naiveté of thinking that it’s like any other skill. CIOs  who are fine human beings, very smart, or physicians who aren’t careerists in IT might not have the transactional, life cycle, and vendor management experience that CIOs do in other industries. This is hard. You could argue that health software and health IT is harder because it’s in an environment different than other industries, with more regulation, more change, more third-party roles, government paying for some, and health privacy.

You need more skills and ruggedness in your contracts, supply planning, and IT strategy than in finance, manufacturing, or consumer goods. Maybe I can find some non-profit funding and lure some graduate students to work on their practicum or internships to do records requests. Some of the contracts that I’ve pulled from government hospitals under sunshine laws show work and current supply chains that extend maybe to the dangerous degree that would be unacceptable to the boards of companies in other organizations.

You don’t want to buy the first car off the manufacturing line of a new model. You don’t want to be a first patient of a newly-minted surgeon. Do you want to be a manager of a healthcare provider where the EHR was the first and only IT transaction by somebody? It’s hard.

I know one systems integration vendor who says CIO secretly stands for Career Is Over, because the demands are greater than the time, the funding, and the commercial support in a lot of cases. Unlike some other industries, people haven’t gone and done the epidemiology, the autopsies. In other industries, the selection exercises are way more diligent. They are larger than the selection process. The planning on the front end. Exhibits are process specific, twice as long than in other types of transactions.

What happens is that in a lot of these EHR deals, the customer becomes a captive. That’s evidenced, literally, by the documents that have surfaced in some of the materials that I’ve hunted up and would be the anchor or the database of my possible book. All that’s before the regulatory changes, the more open source software in there. Doctor Gawande’s great book “Better” is the watchword for all of us. A lot of organizations, at least in HIT, are not even at “good” yet. They’re trying to be competent and they’re striving, but whether they’ve gotten to good, much less any best practices, is a real question. Particularly when you drill down and do the lab tests on the actual documents that people are actually operating under.

I’ve pulled out some half a billion dollar, 10-year EHR deals to smaller ambulatory ones and specialty groups. It’s scary how weak the supply chain is in healthcare software as opposed to some other industries. You wouldn’t rely, you wouldn’t invest in it if you knew the standards of others knowing the delta of the difference.

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August 29, 2016 Interviews No Comments

HIStalk Interviews Howard Messing, President and CEO, Meditech

July 14, 2016 Interviews 6 Comments

Howard Messing is president and CEO of Meditech of Westwood, MA.

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Tell me about yourself and the company.

I’m CEO of Meditech, one of the founders of the EHR industry. I’ve been here for almost the entire history of Meditech. I have a very strong technical background. I think if you looked in the dictionary under “computer nerd,” you’d see my picture there. I’ve been here since 1974.

Combined with my computer nerd background, I’ve also dedicated my life to the healthcare industry and making sure that we can proceed and use our systems and electronic health records — although we didn’t call them that back in the early 1970s — to improve care, improve productivity, and hopefully control costs, though we know that’s been a continuing challenge for the entire industry.

I always like looking at those black and white 1960s pictures on your site, like seeing Neil Pappalardo up to his waist in water trying to save the data center.

Believe it or not, that was actually in Phoenix. People don’t think of floods in Phoenix, but that was a water main break.

How many hospitals run full-blown Meditech hospital-wide?

We actually have very few customers any more who have just one or two products. The vast majority of our customers are dedicated to our entire portfolio. We have somewhere around 2,300 or 2,400 hospital sites worldwide running our systems.

When we last spoke a few years ago, you priority was to move customers off older product versions like Magic. How is that progressing?

That was the priority then, and to be honest, it’s still a priority. The staying power of our older platform has surprised us. We still have approximately 800 customers on our oldest Magic platform and a similar number, perhaps even a few, more on our Client/Server platform. We have close to 600 on our 6.x platform.

We have a brand new platform. 6.x is the underlying technology, but we’ve redone the entire front end of our products to be Web- and mobile-based for the ambulatory solution and for the clinicians on the inpatient side. It’s really quite a brand new system.

Unfortunately, when many people think of Meditech, they think of our systems that were introduced 20 or 30 years ago because that’s still the bulk of our customers. Keep watching us, because we’re introducing brand new products that are quite different than the rest of the marketplace.

Do you still have to make the argument that customers should value the benefits of software rather than having the latest, coolest underlying technology?

I agree with that in general. One of the main issues right now in EHR, maybe the main issue, is while keeping patients safe, we want to make sure that clinician productivity is not hurt. For the last 10 or 15 years, the entire industry has been saying, “Go to our systems and you won’t lose any productivity.”

We think that’s the wrong message.  We want to say, “Go to our systems and we’ll improve productivity.” We think by adopting modern user interfaces — we’ve achieved that and have some numbers to back it up — that’s going to differentiate us moving forward as these products get adopted.

Articles that blame EHRs for physician dissatisfaction usually fail to differentiate between community-based providers who have occasional interaction with one or more hospitals and those physicians who work full time in a hospital. How did your studies measure productivity?

I’ll first add that the other issue we see with physician dissatisfaction is the change in what is required of physicians over the same period of time that we’ve been adopting EHRs over the last five to 10 years. It’s sometimes difficult for physicians — and it’s difficult for us — to understand how much of their dissatisfaction is due to poor implementations of software from vendors and how much of it is due to the fact that they are required to document more, provide more statistics, and do more inspection of data. Maybe some will view that as an excuse, and perhaps it has been.

When we look at productivity, what we look at is the very standard kinds of measures. How long does it take a physician or clinician to get through an encounter? One good measure of that is clicks or taps. We have a customer who has done a study looking at the older systems and then looking at our new Web-based product. They found there’s about half the number of taps or swipes than there were with the older systems’ clicks. The amount of time it takes them to get through an encounter is approximately half.

We don’t have the firm data to back it up yet because it’s a new system for us. We only have four or five Web-based ambulatory systems up and running. Our Web-based acute care system is actually just being delivered this summer. We’re pretty excited about the implications that will have for productivity of clinicians, of course while maintaining safety of the patients and providing the best possible care. Maybe as importantly, keeping costs within a reasonable realm.

How well is Meditech competing with Cerner and Epic in getting new customers and keeping existing ones?

We’re certainly keeping our old customers pretty well. We have a lot of old customers. Our maintenance revenue keeps going up.

We have seen a little bit of a pause over the last couple years in acquiring new customers as people wait for these newer user interfaces to be delivered. We’ve still managed to convince a fair number of our existing customers and a handful of new customers to join us in pursuit of this new product. We think that will pick up next year.

How do approach the market knowing that you have to displace someone else’s product?

That’s a challenge. It is very much not a new market, it’s a replacement market. We go in making the case that both our products can help increase provider productivity.

Then we also make the cost-based argument. We think that we are far and away the most reasonable total cost of ownership vendor of the three major vendors. It’s a little bit obscene the amount of money that some of the healthcare industry is spending on some of these systems. We can make a good dollars-and-cents argument that going with Meditech will save them money. Particularly when you consider that no matter who gets elected in the next election, nobody’s expecting our government or payers to be paying more for healthcare episodes and for healthcare in the future. As we move to population health, that’s a way of achieving better health, but also controlling costs.

In general, there needs to be some ceiling placed on what is spent on electronic health records. We think we have the right answer with that and that’s the major argument we make. You can get a new, modern system; a system that will increase your physicians’ productivity; and you can do it for less cost than with the other vendors.

Is it hard to get someone who spent dozens or hundreds of millions of dollars to implement Epic or Cerner to admit that they made a financial mistake and go back and replace it with Meditech?

If they’ve just spent the money, it’s hard. We have to make the argument as these systems age, although we have had some success with people who have made that commitment and then realized what they’ve gotten themselves into.

The company’s product revenue has dropped by around half since 2013, which directly hit net income. What’s the cause and how do you fix it?

Net income is down. On the other hand, we are still strongly profitable, still paying a dividend, and still giving our employees raises and bonuses. We have a very strong balance sheet.

A lot of this was anticipated as we moved towards the new user interface that we’ve provided for our products. We’ve seen a lot of people waiting to buy that. We also have lost a handful of customers to consolidation, where people are acquired. There’s not much we can do if they’ve decided on going with another vendor’s system. We’ve seen a slowdown in that loss. 

This year, we’re doing relatively well. We expect that to turn around over the next 12-18 months as people start to see the effects of our new products.

Some of the market change involves hosting of client systems, which Cerner has built into a big business as Epic cautiously tests the waters. What does Meditech offer customers who want to turn over EHR system operations to their vendor?

We’ve actually offered, through third parties, the ability to do that for quite a while. There are a fair number of our customers who already are hosted by a third party, just not by Meditech. We’re also looking at whether we ourselves want to brand the entire system and provide it. We’re looking at some efforts, particularly at the smaller hospitals, and introducing that over the course of the next 6-12 months.

How do you see the potential change of ownership of McKesson’s Paragon product line changing the market?

I’m not sure it changes the market. I think everybody has been anticipating that McKesson was not very interested in pursuing their product line over the last 12 or 18 months. If this new arrangement involves a significant investment in R&D, perhaps they’ll be able to turn that around and become a significant force in the marketplace again. If they don’t do that, then I’m sure it will just be a winding down over time. I have no idea and am not privy to their deal to know what’s involved.

To be honest, we haven’t seen them as a very strong competitive force for two or three or four years. It’s very much a three-horse race on the acute care side among Epic, Cerner, and ourselves. Perhaps if you throw in the ambulatory side, there’s another couple of vendors that are strong and that we know are trying to get into the acute care space. The future clearly is in being able to provide services to the entire spectrum of healthcare — acute care, ambulatory, mental health, long-term care, urgent care, wherever healthcare is being provided. Particularly as population health begins to assert itself over the next few years.

Ambulatory was a perceived weakness of Meditech compared to Epic and Cerner. Is that changing?

Absolutely. I agree — we stayed away from the ambulatory sphere probably for too long. Then about 4-5 years ago, we acquired a long-term partner of ours, LSS Software, with the expectation that that might fill the gap for us. But we quickly began to realize that there were some issues with having a separate system. We bit the bullet, so to speak, and three years ago started developing our own ambulatory system and chose that as the testing ground of our new mobile and Web-based technology.

We’re happy to report that that product is now out in the marketplace. It’s live at four or five sites. We have orders for approximately 15 or 20 more of these systems. We see it as a big improvement on what our competitors offer, both in the functionality it offers specifically in the ambulatory space and also in the ability to integrate completely with the total healthcare enterprise.

Your Boston neighbors Athenahealth and EClinicalWorks are trying to push their way into inpatient from the ambulatory side. How do you see that developing?

Those were the two I was specifically thinking of when I said there are a couple of vendors trying to get into the acute care space. We’ll see what happens. They’re both good companies, both run by able leaders. We’ll see if they’re successful in getting into the marketplace.

Just as we’ve been learning about ambulatory and what it takes to provide an ambulatory system — and honestly there’s more to it than it seems when you first look at it –  we think they’ll have the same kinds of experience as they push into acute care and learn that there’s a whole lot to it. We’re welcome to take them on competitively.

Some people think inpatient systems are just EHRs, but Meditech offers complete departmental automation rather than just maintaining a patient record. Will companies like EClinicalWorks and Athenahealth need to get out into the hospital department operations to be successful?

They really have to get out into the departmental operations. They will discover that those are pretty complex and difficult to do.

To be honest, in the future, I believe that with the rise of FHIR and other API technologies, that might not be as important. Certainly as a technologist, I think that eventually that’s the right way to go. I still think we’re several years, if not the better part of a decade, from actually having that kind of capability as standard in the healthcare industry.

When that happens, perhaps it will be easier to provide an EHR that doesn’t also provide departmental systems. For right now, those particular integrations — particularly between pharmacy and the rest of the EHR — are very tightly coupled. It’s difficult to see how you can provide that without going into the departments as well.

How would you assess the interoperability capabilities of Meditech and its two significant competitors and their progress toward offering APIs as ONC is emphasizing?

I don’t like to comment negatively about my competition, so I’ll just say that you couldn’t be more dedicated to interoperability than we are. We’re involved in all the major industry efforts to do that. We are one of the founding members of the FHIR effort.

We currently do, I think, as much if not more interoperability than anyone else. There are hundreds of billions of data transactions a year going through Meditech’s systems interoperably. I think the last time we looked it was 300 billion, with 200,000 different interfaces. We’re well on our way to already supporting interoperability, both because it’s required and actually because it’s the right thing to do.

The CIO of one of your highest-profile clients told me he was shocked at how easy it was to turn on interoperability with Meditech compared to the systems of a couple of your competitors that his health system also uses. Would that surprise people?

I don’t know if that would surprise people. It doesn’t surprise me, although I’d like to know who that is [laughs].

We have from the get-go always had an interest in interoperability. I used to give a talk maybe 10 years ago about how in “Star Trek” they get your medical records on the other side of the galaxy. If we’re going to be able to do that in 200 years, we have to get started now. We’ve been pushing for that. 

It’s very pleasing to see that we’ve gotten as far as we have, particularly because the healthcare industry still doesn’t have, from my point of view, the right incentives in place to encourage people to interoperate. For the most part, it’s being done because it’s required as part of government programs. I think that that will change over time.

You mentioned the demand from customers for population health management and analytics. That market is pretty frothy, with a lot of companies popping up out of nowhere. How would you characterize the market for population health management and analytics and Meditech’s place in it?

I’m glad you asked that because we think we are a little bit different in our approach to population health.

First of all, it’s obviously currently one of the big buzzwords in our industry. It’s a clear trend to a way to manage patient population-based health. It’s going to become more and more important as our population ages and has multiple conditions and multiple chronic diseases. We think it’s an important thing.

On the other hand, there’s a lot of people playing on the fears of our customers and of the healthcare industry that if they don’t jump on the bandwagon right now with this particular model of population health, they’ll be left behind. We think population health needs to be a lot more integrated with the care delivery system than some of our competitors. Our approach is embedded in everything that we do. We’re taking a holistic approach to it, making sure that our customers can define and then manipulate and understand the various populations, no matter what their definitions are, as they practice their healthcare.

With the newly-announced MACRA regulations, it’s not even obvious that a physician can always tell which patients are in the population they’re responsible for and counting towards their statistics versus which ones are outliers that they are not responsible for. Our point of view is to give them that knowledge at the point of care, not on some separate list that someone has to compile and deal with on a different basis. We’re doing that by embedding that in their system. We have patient registries. We have a newly introduced analytics product that enables them to slice and dice the data about populations, but then build that into case management capabilities, build that into their revenue cycle issues, and maybe as importantly also relate to patient portal so that the patient can get involved.

One of the things about population health is figuring out how to get patients much more involved in their care. That’s been a Holy Grail. Nobody’s really achieved it very well yet. We want to make sure that we have all the tools in place to allow our customers to do that as we figure out how to get patients responsible for their own health.

Meditech’s executives all grew up within the company. How is their lack of industry experience outside of Meditech a strength when it comes to innovation?

It’s true that our most senior staff are from within the company, but we certainly do hire a lot of people who have not worked here before. We have a lot of smart people. There’s certainly no lack of outside ideas and influences.

In particular, over the last four or five years, we’ve hired a number of physicians into relatively senior positions here at Meditech. They certainly bring a lot of very interesting perspectives and ideas to us. We think that’s made a very big difference in the way that we approach development, implementation, and ongoing support. It’s been a bit of an eye-opener for a lot of us. That’s been a major factor in doing that.

There are both advantages and disadvantages to having long-term senior staff. We’re quite aware of that and try to capitalize on the advantages and make sure that we don’t get complacent about the things that are disadvantages.

How do you prepare for having executives and board members who have been with the company for 40 or 50 years turning it over to the next generation?

Obviously that’s one of the biggest discussions that our board has. We just appointed a new female board member. I wouldn’t be surprised if there were other board changes over time, looking for other people. We also just recently announced a new chief operating officer at the company, Michelle O’Connor, who is quite a bit younger than me and has not been here quite as long as I’ve been here.

We do talk about succession and the next generation. I’m not quite ready to retire. I don’t know that I’ll ever retire, but I certainly like to surround myself with a bunch of, I’ll say, younger people with good ideas. Talk about the future and make sure that the company traditions that are good are maintained and that the traditions that are not good are not maintained. Always ask the question when we do something. If somebody ever answers to me, “Because we’ve always done it that way,” I get very upset. We want to make sure that we’re justifying anything that we do and it’s not simply based on rote repetition of the past.

There’s quite a bit of overlap in the histories of Meditech and Epic, with one factor being that both companies have steered clear of the limelight with little interest in interacting with anyone other than customers and no real marketing or press presence. Epic seems to be opening up a bit. Is Meditech doing the same?

Absolutely. It’s one of the biggest things I’ve wanted to change in the five or six years I’ve been CEO. We’ve been working hard on it.

You touched on it yourself earlier when you pointed out that it’s a replacement market today, that it’s much more difficult to acquire customers. It’s also that the world in general is a much more marketing-oriented world. To be perfectly honest, we were founded by a bunch of MIT engineers, of which I’m one. I was here from the early days and we used to have the old mentality of, “If you build it, they will come.” Clearly that doesn’t work in the modern world, so we want to get our message out there.

Combine that with what I said early in the interview that we have a lot of older customers that we continue to support, but that means that many people continue to associate Meditech with our 20- and 30-year-old systems. We feel the imperative to get the word out that if you’re buying something new from us today, it is new. You’re not buying that 30-year-old Magic system.

All that has led us to believe we need to spend more time and more money on marketing. Hopefully, though, we’ll still be the relatively laid back, not overly slick vendor in providing that kind of information to the marketplace so they can make their decisions based on functionality and cost.

Where do you see the company going in the next five years?

In some ways, we’ll be doing the same things we do today. We’re dedicated to the healthcare market. We want to provide a complete, sophisticated solution for all the modalities of care.

There’s going to be a lot of challenges in healthcare no matter which direction our government takes. There’s going to be many challenges over the next few years. We want to make sure that our existing and prospective customers are prepared to handle that.

We need to polish off the new systems we have, extend those, then make sure that ancillary markets are also well served. In addition, I’d personally like to see our international share grow. We have close to half of the English-speaking market in Canada. The rest of the world is ripe to see the same kind of advances that we’ve had here in EHRs.

Do you have any final thoughts?

It will be interesting to see how the healthcare marketplace develops. We certainly intend to be a major player in how that transpires.

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July 14, 2016 Interviews 6 Comments

HIStalk Interviews Steven Liu, MD, Chief Medical Officer, Ingenious Med

June 27, 2016 Interviews No Comments

Steven Liu, MD is founder and chief medical officer of Ingenious Med of Atlanta, GA.

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Tell me about yourself and the company.

I’m the chief medical officer and founder of Ingenious Med, going back to 1999. I’m also a practicing physician. I started the company as a solution to help me as a clinician manage the practice and to capture charges and data.

Since we last talked in our interview four years ago, we’ve gotten way bigger and moved toward what we call the Right Side of Healthcare. We’re focused on helping clinicians change their behavior. We’re focused on cost reduction.

Describe the day in the life of a physician interacting with your system.

The platform is cloud- and mobile-based. We’ve moved outside of just physicians, which used to be our bread and butter. Now it’s physicians and the care team members who surround them — nurses, case managers, pharmacy, whoever. We have a heavy emphasis on the acute care space, the hospital space, where there’s a large part of cost.

The world is different these days. Clinicians have wear two hats. They have to put on the hat for their practice. But then they put on a second hat after they take care of the practice and do pro fees and work capture if they’re at risk. Then they focus on those other incentives to line up with their healthcare system — hospital throughput, transition, reducing readmission, and reducing avoidable days. All of those cost and quality things that weren’t front and center in traditional reimbursement schemes.

At the point of care, they use us on every single patient. We whisper back information, things that will change their behavior and make the entire acute care process more efficient. The results we’re getting are driving a lot of our growth these days.

People who work in academic medical centers sometimes forget that most of the non-hospitalist doctors in community hospitals work in their own practices and spend minimal time in hospitals, sometimes in more than one hospital using more than one information system. How hard is it to integrate those doctors with hospital-based care teams?

That’s part of our secret sauce. Because of our roots from way back when the majority of clinicians were affiliated — the employed drive hadn’t really taken off in the early 2000s — we grew our bones on affiliated private practice physicians. That’s how we got a great footprint. About five years ago, we started to become involved with enterprise enterprise rollouts with employed as well as affiliated physicians. The system was designed and being used by affiliated physicians.

You can think of us as a bridge. Alignment is a big focus of our company. The alignment is focused on the employed physicians, obviously, but the nice thing about it is that we’ve got the affiliated doctors.

I probably shouldn’t say this in this interview, but when we released our coordinated platform two years ago, I was trying to come up with brief wording on what to call it. I was saying, “It’s a clinician risk alignment platform” until someone pointed out that the acronym for that is CRAP. [laughs] I swear I didn’t catch that.

Still, that’s what it is. We’re agnostic to the EMR, sites, locations, and the employment model. We can change behavior.

It’s hard to get doctors to use something that doesn’t benefit them directly. What’s the “what’s in it for me” story for users?

Times are changing. A lot of people looked at us strangely when we said we can’t wait for MACRA, MIPS, and the drivers that are coming next year and in 2019.

As incentives change and people start to feel the pain, they have to align. Private physicians can’t keep their heads down and think of themselves as separate entities. To survive, especially for standalone practices, they’ve got to deliver on cost reductions and quality. Part of our platform is maximizing the revenue portion, but the other part addresses those other things like cost and bed days.

The conversations we’re having with clients or prospective clients are very much all about preparing for the new world of risk value-based reimbursement. All of our large enterprise deals are for what we do now, but also as they take on more risk contracts, all the stuff we’re doing with coordinate. They’re all preparing, although the industry is still moving slowly despite all this government push.

What is the low-hanging fruit of care team coordination?

One is alignment of incentives. If the hospital employs their physicians or if they have affiliations with practices, just based off their relationships with those physicians, the alignment incentives or reimbursement models that they have with those clinicians. If they’re not aligned and it’s straight, traditional fee-for-service, they’re not going to get the benefit. As long as the clinicians are aligned on reducing costs, being efficient, and having high quality, that’s a big, big one. It’s hard. It’s really hard.

Secondly, in the acute care space — even though that’s not where we primarily practice these days – it’s collaboration between disciplines. I’m not talking physician disciplines, but all the care team members. It’s still back in the Stone Age. When we go on site, sometimes there’s just no incentive for the physician to call up the case manager and spend an extra five minutes collaborating so they can get someone out safely that day as opposed to two days later.

There’s so much fat within the acute care space. A lot of people don’t realize it’s not a sunk cost. It really is a tremendous amount of inefficiency there that could be turned around.

You’ve had a long run with the company with changing technologies, getting funding, and bringing in new management. What are the top two or three lessons you’ve learned?

As the original founder, one learning point is that as the company grows, you need to grow with it. A lot of folks will be a little slow on the transition to bringing in senior talent, or in my case, bringing in a CEO to replace me, which I’ve done. We scaled and grew faster because we were able to split duties as we each focused on the important parts of the business that were critical to our success. That was one big one. If you can balance your ego for the bigger picture of the company, it’s so much more successful. You can grow faster and you have a broader talent base to execute.

Things change. The market changes. There’s a great saying: “If you’re coasting, you’re going downhill.” It’s so true. Innovation is a huge, huge part of being able to still kill it 15 or 16 years later.

It was probably right around when we had our last interview when we kicked off our next stage of innovation of, “How do we prepare for where the hockey puck is going?‘’ If it hadn’t been for that, we’d be in trouble. We would have a solution that was great that had great returns in the here and now, but wasn’t something that could also take the company to the next level as the world turned into value-based reform.

A constant focus on innovation and keeping an eye out for that. Innovation is hard. It’s not something that you can just pull out of the air and make happen. It is that right time, right place, and right mindset. Luck as well. We got lucky in a way and came up with a really wonderful solution.

You have health systems as investors. What value are health systems getting from creating their own venture funds or working with accelerators?

It makes sense. If you went to JP Morgan this year, every PowerPoint slide was about the incubators and investments the health systems are doing. It was more than I had ever seen. It’s a great idea. It helps them invest in technology they’re already interested in or are rolling out and to have an ability to influence it. 

We went through a majority recapitalization in October 2014 with North Bridge Growth Equity, but we ended up bringing in three other strategic investors — Ascension Health, Heritage Partners in Nashville, and Kaiser Ventures. What’s neat about it for companies is that you get to work with industry leaders. With the portfolio companies within those four investors, seven of the top 10 largest healthcare systems are investors within our company. We get to build for the nation’s largest healthcare systems. 

It’s great for us. Obviously you get contacts and many of them were already our clients, but it’s a great way for the healthcare systems that are investing to get exposed to transformative technologies that will help them pave their path to the new world, where it is a Wild West of technologies out there.

Do you have any final thoughts?

Our company has done well. We’ve really grown. We are used on one in five hospital admissions across the nation, so 20 percent of the nation’s hospitalized patients go through our system. It’s exciting to me because we’re whispering in the clinician’s ear at the point of care and influencing their behavior. It’s a responsibility, but also an opportunity to move the dial, change their behavior, and reduce cost.

I’m excited by the opportunity that I never imagined we would be given. We’re focused on all the things we could be doing to influence care. There’s nothing like being able to tell your employees that you might be able to change healthcare across the nation. It’s a fun and very stirring thing to be able to do. That’s what’s most exciting for me.

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June 27, 2016 Interviews No Comments

HIStalk Interviews Lisa Maki, CEO, PokitDok

June 1, 2016 Interviews 2 Comments

Lisa Maki is co-founder and CEO of PokitDok of San Mateo, CA.

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Tell me about yourself and the company.

I’m the co-founder and CEO of PokitDok. We’re a digital health company providing an open platform of APIs streamlining the business of health.

Explain how APIs work and the types commonly found in healthcare.

I started in software back in 1989, working on pre-Windows DOS versions of consumer and enterprise-facing software. I did that at Microsoft. Over the years, as software evolved into many industries, health included, it became clear that you needed services that would connect different siloed sources of data, different siloed sources of functionality, so that the enterprise IT professional software developers could create seamless business, user, and consumer experiences across all those silos.

How that shows up in healthcare increasingly is a set of APIs that can give access to interoperability, exchanging data between the EHRs and others in the form of standards that FHIR supports. APIs like ours that connect you to insurance X12 EDI or eligibility, claims, benefit enrollment, pre-authorizations.

The beauty of an API is it can be integrated anywhere into new digital or existing products. It doesn’t need to dictate your user experience. It can integrate into it and provide that service as you think best fits your business model or your user experience.

Non-technologists might think that APIs are pain-free and foolproof, providing instant interoperability. What are the challenges involved, both technical and non-technical?

APIs are intended to do the underlying infrastructure or operating system heavy lifting for software developers and IT professionals. It doesn’t remove work. It still assumes that you’re doing some work on your side to build the product or integrate it into the product.

In the case of our APIs that connect to insurance companies for access to X12 EDI services, eligibility and claims, those insurance companies — that’s over 400 now — still change their endpoints, those things we’re connecting to, often on a daily basis. 

Part of the value that we provide software developers is we keep track of that. We detect it. We adapt to it. We manage that so software developers don’t have to. They have one endpoint they can go to and they can get access to all those insurance companies, all those services. The value we provide is managing that complexity on the back end.

But that software developer still has to integrate that into their own software, perhaps into a very complex system on their side. Maybe they service multiple EHRs, multiple practice management systems, in one single healthcare system, especially with consolidation. That can be very challenging and a lot of work.

It’s not an instant solution. It does a lot of the heavy lifting to get to that solution.

We also provide an identity management API that is not open like our others. We want to talk to you first because it is complex. Sometimes we assist our customers to put in an identity management solution across their health system because they have several instances of the same person in many different repositories. That identity management solution gets them to one instance of it.

But yes, there’s work involved. It’s not a switch. It’s not an on and off.

How do companies or systems that offer APIs coordinate software changes so that the end-to-end functionality won’t be broken?

It starts at the heart of how you architect your APIs. If you are architecting your APIs such that it requires a change in configuration every time — say in our case, an insurance company changes their endpoint or their gateway — then you haven’t done a good job architecting. That’s the bottom line. We have architected our APIs so that we can handle those changes and not put that burden on the users of our APIs. There can be exceptions to that, but a large part of our value is removing that burden.

There are things that we can’t control, like downtime of the insurance companies or changes for our identity management solutions. For example, I can’t control whether or not Cerner, Epic, or Allscripts is changing something about your installation, but I can certainly architect it to remove the majority of the heavy lifting. That onus is on all of us who are API providers. We have to architect that correctly.

We also have to provide open and transparent dashboards for our customers. For developers, one of the things we provide — and encourage any other API provider to also give their customers — is transparency all the way through the development process. You’re making an API call. You should know exactly where that API call is in the process. If something is being held up, you should know where in the system and where in the call, for what reasons, and get all of that feedback in real time.

That’s something we provide our development customers. If it’s downtime of a major insurance trading partner, they should be able to communicate that to their customers in real time with transparent information. For things we can’t control like that, it’s the goal to be as transparent as possible so that our customers can as well.

Much of the interoperability barrier is cultural rather than technical. What elements of trust or permissions have to be built into APIs so that data can move freely?

You hit the nail on the head. There are no technical reasons why we can’t have interoperability in healthcare. There are absolutely no technical reasons. Most of these technical obstacles have been solved back in the 1990s in other industries that are equally complex. Financial — heavily regulated, very complex — has addressed these issues.

You have to have a will to achieve a business model and create a business model that rewards interoperability and openness instead of closed systems. Most of the time, we’re overcoming habit. We’re overcoming misinformation around security and compliance. There’s confusion over what the P for HIPAA stands for. It stands for portability. There’s a lot of behavioral issues that have to be overcome to achieve the interoperability that we all want.

A lot of progress is being made. The progress is being made because the market has shifted. Any time you see someone like us and a company like PokitDok going into a market like healthcare … we’re not healthcare experts. We’re technology experts who want to make the tools available so that people who are experts in healthcare can create the patient onboarding experiences and the business models they need to support their business in this changing market.

We come in because there has been a market shift, like you see with consumers moving to  high-deductible plans. All of a sudden consumers are starting to change their behavior. They have to pay for it out of pocket. They’re demanding more transparency and service at the point of scheduling or checking in before they have the procedure. That’s a huge market shift.

In order for health systems to respond to that, to compete, to protect their revenue cycle stability instead of seeing their former reimbursement revenue now go to collections, they need new tools. They need the ability to schedule, check eligibility, and take a payment in real time, both mobile and Web-based. That’s what we respond to. 

The market shift is overcoming any behavioral or former business model resistance, both from EHR and API providers.

What healthcare APIs are most commonly used and most needed?

There are not a lot of APIs available in healthcare that would fit my definition of a developer-ready open API. We are one set. FHIR is certainly another, early but evolving and getting a lot of interest. There are certainly your standard developer APIs, when you’re creating that new product from software technology providers.

Early efforts from CommonWell and other alliances are attempting to provide API access. EHR vendors like Cerner and others are looking to release access to APIs. Even sandboxes represented by Athena, Epic, Allscripts, or Greenway are heavily business model controlled API sets. They require a lot of heavy lifting, a lot of time and interaction in a sandbox before you can take something to market quickly.

Today’s software developers who are building truly innovative solutions for either their own or for their customers in healthcare expect modern API experiences, not sandboxes. Not long, lengthy vetting processes to get something to market. We’re seeing some interesting things from companies like Redox who are doing intra-EHR interoperability. There’s some interesting things from companies like PatientPing. I’m excited by this because they’re following more of the modern developer standard and expectation for open APIs. I think the market will follow.

Most of the handful of surviving hospital EHRs use a 1990s style client-server architecture at best. Are those companies up to the task of creating scalable, secure APIs that use more modern technologies than their own products?

It’s a huge cultural shift for those companies. My co-founder and I both come from companies like Microsoft and Apple and various startups. We’ve released product into many industries and now healthcare for the past 10 years. It’s going to take an immense amount of leadership in those companies to prepare them for this shift.

It must and will happen. New technologies are showing up every day that will make the shift for them whether or not they’re ready. If I were in those leadership positions of those companies, I would be starting parallel projects with people who are used to those sorts of open and technologically advanced environments, cloud-based Web services. I would start that now if you haven’t already and I would start it really fast, because it is coming and it’s likely that with your current systems, all you will be doing is migrating them over.

You will need a different set of people familiar with with building and supporting those systems. If you haven’t already started it, then starting it today would be your next best bet.

I would also partner. You’ve got companies like Microsoft who are trying to build API-driven architectures that do much of the heavy lifting, even compliance and security, into the fabric of Azure, their cloud offering for healthcare enterprise development. You’re going to see a lot more of that.

EHRs also have to get clear on what part of this they are going to own moving forward as the business shifts to the cloud. Which part will be owned by companies like Microsoft, Google, Oracle, and IBM that will be built into the cloud fabric. You want to get clear on that quickly because it affects your strategy.

Where do you see the company going in the next five years?

We want to be the house for all healthcare enterprise business transactions. We hope to achieve that in five years. That’s our big goal. There are a lot of unnecessary ones that add friction and operational cost to healthcare enterprise today that we hope to remove and then there are new ones that we hope to add.

There’s no reason why our healthcare customers — and this is what we provide them today — shouldn’t be getting up-to-date and real-time business outlooks and intelligence off of all their business transactions today. There’s no technical reason why they can’t have it. That’s what we deliver and that’s what we want the entire healthcare industry to be enjoying from its business and ultimately clinical transactions on a daily basis.

Do you have any final thoughts?

I love what you’re doing. These sorts of conversations, as the industry is going through such a massive market and technical shift, are super-important. More of us talking about what is technically possible and identifying, as you’ve astutely said, the behavioral and business impediments to healthcare enterprise moving forward to deliver the kinds of patient, provider, and business experiences it needs to. Those are the right topics.

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June 1, 2016 Interviews 2 Comments

HIStalk Interviews Brad Huerta, CEO, Lost Rivers Medical Center

May 25, 2016 Interviews 1 Comment

Brad Huerta is CEO of Lost Rivers Medical Center of Arco, ID.

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Tell me about yourself and the hospital.

I am the chief executive officer of Lost Rivers Medical Center. We are a Critical Access Hospital in central Idaho. We are located in two really different communities in the middle of Idaho. One is Arco, Idaho, where we have our hospital and our rural health care clinic. The other is Mackay, Idaho, where we run a rural healthcare clinic.

The hospital itself is in fact a hospital district. We’re a taxing district. We operate in a geographical boundary that is larger than the state of Rhode Island. Despite that, we have fewer than 8,000 people in terms of population in that district. We are in an extraordinarily rural, mountainous area in the middle of Idaho. The census bureau doesn’t even consider us rural – we’re considered a frontier hospital because of the population density. We are in the middle of the wilderness.

As big health systems get bigger, are Critical Access Hospitals getting lost in the shuffle?

One of our biggest obstacles to overcome is the remoteness. You see that a lot with recruiting specialties in here, and sometimes on the technology side. There are a lot of additional considerations that we have to deal with that maybe larger hospitals, tertiary hospitals, and MSAs don’t have to focus on. The flip side of that coin is that one of the greatest benefits we have is the fact that we are remote. We have a very specific audience. We’ve cornered the market, if you will, in our area. That part is kind of helpful as well.

Are you using remote services or telemedicine to access expertise outside your geographic area?

Absolutely. In my own humble opinion, remote technology is the greatest force multiplier Critical Access Hospitals have at their disposal. We utilize a significant amount of telemedicine with a remote presence specialist that comes in from the University of Utah, Level One trauma centers, burn centers, telestroke, tele-STEMI, tele-ED, tele-behavioral health. These are things that, because of our location and our remoteness, we simply could not offer and certainly could never hope to recruit for in our area, short of any physician that just really loves to fly fish or go hunting. We use that quite a bit.

Our hospital was the very first hospital in the state of Idaho to utilize telepharmacy in conjunction with Idaho State University. We rely heavily on it. We are big adopters of it. We oftentimes are on the leading edge of technology for small hospitals. Certainly in Idaho, I think we are. It’s a huge part of our service lines and our mix of how we offer services.

We picked Athenahealth because of that. We talk about recruiting physicians, medical specialties, nurses, or whatever it is, but hospitals of my size in the middle of nowhere also have recruiting issues for IT people. One of the reasons we picked Athena was because at the time that we made this decision, about 18 months ago, they were the only strong platform for cloud-based EMR. We had come from another platform that wasn’t offering that.

Now it’s become the standard, but 18 months ago, one of the big things for me was that I can’t afford to have a server farm at my hospital. And even if I bought $100,000 worth of servers, I don’t have an IT person who can come out here and babysit those 24 hours a day. The remoteness piece, we see it on the clinical side in the applications that we use for patient care, but there is also these other externalities that often get overlooked, and part of that is the IT equation. Certainly anything we can throw in the cloud or do remotely — whether it’s patient care or patient records or EMR — that is something that we absolutely adopt.

Every patient room and clinic room utilizes an IBM thin client for uploading patient documentation or patient records, all done in real time. We do have servers and I do have kind of a part-time IT guy who lives here. He also does fire safety and telephones and everything else, but it’s mostly minimal. A lot of the on-site stuff for technical assistance we contract out with a company out of Idaho Falls, Idaho. They come up about once a month just to kind of kick the tires to make sure we have all of the right updates and all of that.

The Athenahealth platform was critical for us because it’s all cloud based. We utilize several components of their platform. Our entire outpatient or clinic population is managed by the Athenahealth platform. Our entire billing department is managed by Athenahealth. Our entire emergency room and acute care wing is managed by Athenahealth, and we are just doing that implementation right now as of last week. We are also doing all of our purchasing with the Athena Jump Stock program. We’ll have a unified platform across all of the hospital operations.

What are the most pressing hospital issues?

We came from a dated 1993 Healthland platform that we were getting no value out of. Small hospitals kick every rock over and hit every bush we can for revenue. One of the important things for us was making Meaningful Use attestation for Stage 1. That was huge. We hit the ground running. I got here about three years ago. We didn’t have a viable EMR. One of the things we had to do to make attestation to get reimbursement was to have an operational EMR right out of the gate. That is really what consumed us for the first 18 months.

Now that we’ve attested successfully and gotten our reimbursement, we are onto different phases of attestation. One of the things that I have enjoyed f is having a unified platform across the clinic, the hospital, the billing, and the purchasing. Instead of having two or three different programs, all of these programs are knit together to give us a unified platform. Not that physicians can’t negotiate different platforms, but the easier we make it on our physicians, the happier they are going to be. If they only have to learn one system, that is a huge employee satisfaction deal for us.

What are you doing with managing populations?

Being a Critical Access Hospital, we want to be the provider of choice. One of the challenges we have in terms of managing our population would be getting the appropriate specialties to  come up here. Like I said, our population is pretty small. The other part of it is that it’s an older population. We don’t deliver a lot of babies, but we do see a lot of trauma. Being rural, we will see a lot of shotgun and hunting incidents, ATV rollovers, horseback incidents, or cattle, these kinds of things.

Having services that cater to an older population from nuts to soup. It’s geriatric psych. Maybe it’s diabetes education or nephrology. We are looking at older population health issues for a crowd that is probably 45 and older, generally speaking. We do have young people, of course, but most of our biggest challenge is focusing on developing service lines that cater to an older population that we can serve by bringing in specialists from outside. That can be kind of a challenge. There’s just not a lot of physicians to be had anyway and there are even fewer that are willing to come out to a remote place like us. That is probably the biggest challenge.

How do you see the next five years?

We have stabilized hospital operations. We’re cash flowing nicely. We are capturing every bit of revenue that we possibly can.

Two main issues concern me. One is a political question, looking at the ongoing election and what is going to happen to healthcare depending on what party takes control. If it is in fact going to be one party, you hear talk of repealing, removing, or replacing the Affordable Care Act. That would cause absolute havoc for every hospital, not just small hospitals.

We’re just now continuing to try to implement the mandates of the ACA. Any type of change now would be catastrophic. That would hurt a lot of hospitals. It’s like steering the Titanic — you just can’t do something one day and turn around and go 180 degrees the next day. These things take time. As we’ve we’ve gone down the path of the Affordable Care Act, whether you like it or not, hospitals have adjusted their operations to start to accommodate that new environment. Any change to that would be extraordinarily difficult.

A component of the ACA is the mandate for accountable care organizations. Or in our case, any type of option that may allow itself to something different, like a CCO, or a community care organization. You are going to be moving towards a value- as opposed to volume-based reimbursement system. On one hand, that is probably a great harbinger for small hospitals because we do great quality care here. Our HCAHPS scores are some of the highest in our state. We are constantly fighting the battle with volume. We do great care, but we just don’t get a lot of patients.

Any payment system that replaces volume for value is a good thing, and I think my hospital in particular is uniquely positioned to do well in that environment. But at issue is some of the restrictions with regards to ACOs, where you are saying, "You have to have population health management.” You have to have a population to do that. If you are talking a population of 75,000 or 150,000 or a half a million people, that is one thing, but I live in a community with 8,000 people. How am I going to share risk and bring value if the reimbursement is tied to a certain percentage or a certain number of covered lives? 

Small hospitals are going to have to look hard at who they want to partner with on these ACOs because you can’t do it by yourself. Rural hospitals with small populations are going to be asked to do population health and we’ve only got small pockets of populations. You are going to have to throw in with shared markets and bigger hospitals. That is not necessarily a bad thing, but certainly you want to be careful of who you partner with.

There is a lot of subtle distinctions between for-profit and not-for-profit and critical access and trauma centers and what kind of trauma centers there are. There is a lot of differences in hospitals. Some of the governing philosophies of what makes sense or doesn’t make sense are going to come into play. There is going to come a time when small hospitals are going to have to decide, are we going band together in an organization — perhaps a community care organization that has maybe a lot of small hospitals making a threshold for population — versus, are we just going to go with the biggest hospital next to us and hope for the best?

That to me is a real challenge that Critical Access Hospitals are going to have to face, probably in the next 18 to 24 months. It’s a mandate. We are going to have to go to value. I guess right now we are all in the dating phase to see who we want to take to the dance.

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May 25, 2016 Interviews 1 Comment

HIStalk Interviews Peter Butler, CEO, Hayes Management Consulting

May 23, 2016 Interviews 2 Comments

Peter Butler is president and CEO of Hayes Management Consulting of Newton Center, MA.

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Tell me about yourself and the company.

I’ve been with Hayes for 22 years. I’ve been running the company since 2007. From a company milestone standpoint, at the end of 2015, we did a management-led buyout and bought Paul Hayes, our founder, out of the company so he could go off into retirement and enjoy the fruits of his work. We’re excited to continue carrying on the legacy.

Hayes started as a consulting company. We started in revenue cycle management and optimization. We grew from there into clinical optimization, always with an IT component, but also the business of delivering care and operating a business. That’s where we got our grounding.

We got into the software business in 2006. We have a software solution that we call MDaudit to help billing compliance managers run their business more efficiently and identify risk areas for their organization.

Sometimes it’s hard to tell whether a given company does true consulting versus providing staffing services. Is that ratio changing in the industry in general?

We’ve seen over the last several years firms that started as consulting firms have become staff augmentation firms, mostly around Epic implementation services. There’s just been so much demand in the industry. Those services have been commoditized over the years.

There’s still a need for consulting firms. Where I see the differentiation is where people can come in and do interim leadership, management, business process change on those levels, coupled with the IT implementations as well.

How does a company grow from just letting their individual warm bodies wing it versus developing mature, repeatable processes?

From repeat types of projects or very similar projects, you develop a methodology that’s  packageable. You can replay that and bring in along with it best practices. What the client is getting is for that targeted effort — whatever that might be, a revenue cycle improvement project — here are the top six steps that we follow and it’s a methodology. Sometimes it’s not a software solution or something that’s easily demoable, but it is a methodology that could be followed.

For example, bringing in key leadership stakeholders, interviewing at that level, understanding what they have a need for, and then dropping down a level into the management level and saying, "What are you really executing in the delivery of your business?" Then looking further, you get into the IT side of things and have a certain methodology there as well that you’re looking for these top 25 items. You put that together in one methodology and you can make some improvement.

Is it easier or harder to recruit people into consulting compared to two or three years ago?

It hasn’t been harder. We tend to see a lot of people who are later in their careers who want to get into consulting if they haven’t been there previously. For them, it’s the thrill of a new project and not being tethered to the politics of any one organization. They also have to have a pretty strong willingness and interest in travel.

For us, it’s been fairly easy to recruit people that are interested in making a difference one project at a time. We haven’t see many people pulling back from the consulting ranks from the types of projects that we’re hiring into.

How important is developing relationships with prospects or current customers?

It’s absolutely critical. I was under the misunderstanding when I solicited Paul Hayes and said, "Can I go out to the West Coast? I’d really like to live out there first of all, but I think there’s some business opportunity.” I thought it would be a matter of setting up a shingle and publishing a phone number on a website.

What I found was a lot of hard work over the next couple of years being a face of an organization, meeting a lot of people, and seeing them on a regular basis at industry conferences or speaking at industry conferences to the point where they knew you and knew what you were capable of and could trust you enough to ask questions. It took awhile to get to that point because, typically, people are very defensive of a new face or new player. Being able to build up that trust  opened up a lot of doors through many many conversations.

What makes someone decide to hire a new firm instead of continuing working with their current one?

You’re really only as good as your last project. Typically, firms will get replaced if they if they stub their toe. The client will cut you some slack if you put a resource if it’s not quite a good cultural fit. They’ll give you an opportunity to replace that person. If you have a couple of events like that, they start to lose confidence in you. Or if you’re asked to present before their board and you’re not prepared enough, or you don’t understand the politics in the room when you walk in, you can really stub your toe there.

Those provide opportunities for firms like us to get an opportunity to, “Give me a shot — I think we can make this right.” Then, you just got to put on your A game.

Can you usually tell ahead of time when a consultant or engagement is having problems?

We try as hard as we can. One of the best ways to do that is a regular touch point with the client. We’re checking in and you’ll hear, "Hey, everything’s going great. Everything’s going great." On a regular tempo, as you’re checking in, you might start to hear, "This meeting didn’t go as well as we thought it would." You make some changes and identify potentially what the reasons were and address it early and often. That’s key to managing client expectation and the way the consultant is presenting themselves.

What are the biggest changes that have occurred in consulting in the last few years?

There’s an incredible amount of anxiety in the industry and attention to detail around expense management and revenue. As we know, there’s a razor-thin line on the healthcare bottom line. That’s only getting tighter. We’re seeing an increased level of need or concern around, “Are we getting every dollar we possibly can? Are we leaving anything on the table? What tools can we employ to help us run our business more efficiently? What reporting functions can I get, dashboards or analytics, that will help us identify risk areas before they become problems?”

What does MDAudit do?

When it first launched, it was really a work flow improvement tool. Clients were using spreadsheets and so forth, a very manual process for conducting physician audits and identifying physicians on a manual basis with no audit. Where are they improperly coding? Where are we as an organization at risk for fraudulent billing?

What it’s morphed into in the last couple of years is, as organizations are buying up practices and adding physicians at a very rapid clip, they’re going out and auditing those physicians — usually after they’re bought — and identifying risk areas and then providing educational opportunities to those physicians to fine tune their coding practices.

What we’re seeing now as a trend is more risk-based audits. Rather than looking at every individual physician, it’s looking at what the RAC auditors are looking for in the current coming year.

There’s a whole list of other auditors who are coming knocking and looking for improper billing practices. Where is my organization most at risk? Seeing that on the dashboard, and being able to drill in and say, the greatest risk is coming from this particular department or these physicians. Let’s go target a training effort there to get them coding properly so we can mitigate that risk and move on. We also see that as an important area with the new billing regulations that are coming out and the diminished need for fee-for-service type billing and being able to run a proactive effort as you’re managing physician billing and facility billing.

How will MACRA impact the industry?

It’s going to be a huge burden to the industry. I feel for the physicians, as Dr. John Halamka mentioned in his blog. It’s going to be difficult to manage. It’s very onerous. But it’s a necessary direction that we need to go as an industry. The larger organizations should be able to deploy the resources around helping position the organization and physician billing appropriately to manage against those metrics. It’s the smaller practices that are going to struggle in meeting the requirements.

Do you have any final thoughts?

It’s an exciting time in the industry. I know it’s painful for many clinicians and physicians. There’s so much work that needs to be done and so much modernization. I look forward to the next 10 years working in this industry and helping our clients to migrate and manage through the process of transitioning from fee-for-service into more of a value-based delivery system. As a patient, I’m really looking forward to that.

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May 23, 2016 Interviews 2 Comments

GE Healthcare Announces Project Northstar

May 18, 2016 Interviews 9 Comments

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GE Healthcare announced this morning at its Centricity Live 2016 user conference in Phoenix, AZ its next-generation IT solution for ambulatory care delivery. I spoke with GE Healthcare IT VP/GM Jon Zimmerman of the company’s value-based care solutions team ahead of the announcement.

Describe Project Northstar that is being announced.

Project Northstar is GE Healthcare’s next-generation IT solution for ambulatory care delivery to fundamentally help practices thrive in the world of value-based care. We strongly believe that the move to value-based care is on. It’s not going to be a light switch. It will be a transition over time.

We also see that the tools and services that have been built around population health have not been integrated with care delivery from a community perspective. It’s certainly not completely integrated with revenue cycle management with both value and volume in mind. Payers are changing, too, so there’s new payer connectivity required.

We’re taking a point of view from a physician’s workflow and driving population health integrated with care delivery, integrated with revenue-cycle management both value and volume, with new forms of payer connectivity to take waste out of the system. Our drive is to increase quality, efficiency, and financial performance for customers.

Is this a standalone product or is it just for Centricity users? Who is the target customer?

The audience starts with GE Centricity Practice Solutions / GE Centricity EMR first, but we built it with open principles. We believe that some of the advanced ACOs may want to take some of the capabilities that we’re offering and also make them useful and integrated on top of other EMRs.

Is it an upgrade or a separate product that Centricity customers will buy?

Look at it as an extension from what people have today with a migration path to roll it over Centricity over the next few years. We believe that a big-bang replacement would be a very bad and disruptive idea. Many of our customers have given us great clues on how to do a safe, smart migration transition. It’s not a big bang, turn that off, turn that on.

What providers and partners did you work with?

We worked with Westmed Practice Partners in Westchester, NY starting almost two years ago. One of the things that was highly attractive about working with Westmed is that they were scoring very high in their quality measures. Their efficiency measures and their ability to collect revenue from their fee- and value-based contracts were also very good. Their leadership knew what they were doing. They knew how they did it.

They were pushing our products up to and beyond their capabilities in order to make that happen. When I thought about how we were going to get to that next generation and who we could work with, I thought it would be good to start with somebody who was so very skilled and who knew us so well. That was Westmed Practice Partners, specifically Dr. Simeon Schwartz, the chairman and CEO.

Was the product built from scratch?

It is not being built from scratch, nor is it being acquired. This was a big discussion that Simeon and I had in the beginning. We are building certain components. We’re also assembling capabilities from different technology providers across the industry.

I don’t think anybody is going to be able to have the time to just go build from scratch, but taking a modern, 21st-century approach is going to be key. We have the luxury of leveraging is a lot of the investments that GE is making with Health Cloud, so this is an extension of what GE is doing as well.

It seems that you’re picturing an ecosystem with components provided by partners. How will that look?

First and foremost, we took a tabula rasa approach, meaning a blank slate. Once we got comfortable with one another in Westmed – and other practices have also helped us design this — one of the keys was, how do you guys work? What do you do all day? We went even to the depths of, with appropriate permissions,observing their delivery of care.

We broke it down with a number of usability experts. GE Corporate, GE Digital has been investing in usability expertise and usability engineers. We leveraged those to break down the work processes of a pretty complex multi-specialty practice. We also focused strongly on, as you would imagine, that primary care is the quarterback, and that user experience is a big deal.

On the business side, we said, how does that work? How can we make a system provide more value for the providers? We broke the providers’ work into basically four areas.

Number one is that I need to understand. When I’m going to see a patient, I need to know a lot about them. How should a system gather that information for me?

Once it gathers that information, I need to know what I’m supposed to do. I need to know how to work. Underneath that is a rules engine that we’ve selected. The rules will be based on what the clinicians want to do. We’ll get rules from specialty societies or individual practices and combinations thereof. They will create a rules-driven system that’s based on a modern user experience with workflow guidance to then get the providers to do what the providers know that they need to do. Our approach here will remove clicks, but also provide consistency through the guidance of the decision-makers for that practice.

The next piece of work is that I need to review and sign. Rules comes in and say, did I do all the things that I’m supposed to do that will be impactful for my volume-driven revenue cycle? Did I document what’s required for my quality reporting?

Last but certainly not least, there’s follow-up care coordination and care management that creates a continuous loop in the system versus a set of independent acts.

For the user experience, we’re using the same technology that Google uses. That’s called AngularJS. For the rules engine, we’ve purchased a commercial rules engine and we’ve put that into our stack. To fill the rules engine, we’re working with a number of practices, with Dr. Schwartz being the first. We have another one signed up specifically for cardiology. We have a workflow engine. Our cloud provider is technologies from GE Health Cloud and supplemented by some things we’ve been doing with Microsoft and Azure over the last few years.

You mentioned reduced clicks and the user experience. You’re not replacing the UI of Centricity, correct?

We had a lot of robust dialogue with our customers on this. The first and greatest impact that we can have is the process of creating intelligent orders — orders that take the context of the patient, the context of the payer, and the context of evidence-based practice and build them into one.

In our initial implementation, users will be in Centricity up to the point where it’s time to create an order. Then the new system takes over seamlessly. It pulls all the information that customers are used to in Centricity. Now you’re into the cloud experience, the next-generation system. Once you complete that set of tasks, we bring you back into the world that you live in.

Physicians spend an awful lot of their time, as they should, in workflows for ordering and diagnosing. That’s why we did that. The more that we talk with customers, they said, "You made absolutely the right choice."

How are you using payer information?

I was one of the lucky people who got to work as a pioneer to invent what we know today as the EDI systems of the US for healthcare starting back in the late 1980s. I have a long-term relationship with working between payers and providers. Just before I came to GE, I was lucky enough to work with a great company called Availity, a provider / payer network owned by 21 Blue Crosses and Humana. I got the opportunity to  understand a lot of the payer processes and what’s missing in the bridge between payers and providers that creates an awful lot of wasted work.

GE was an inaugural investor in the AHIP Innovation Laboratory. AHIP, the payers’ professional association, knew that they had to create more innovation because of the trends that we see. We are inaugural investors.

We are reverse engineering the exchanges of information between payers and providers that goes through phone calls, faxes, physical mail, and portals and embedding that into our current and next-generation systems. A very important point: this is not going to have to wait for a next generation. We’re doing that now.

Let me give you a couple of examples. In Medicare Advantage, being able to prove as a payer that you are closing gaps in care and that patients are getting  good care requires that if the payers see that things are not happening at differential analysis, then we can take a gap in care directly from a payers’ system. Some are pushing them out through sidecars and eligibility transactions. We put that information into the providers’ workflow so the know what’s necessary to be done. Then the providers can use their normal processes to get the work done and deliver the care.

Then payers are going to want it reported back. They’ll  take it through a claim, or some are asking for CCDAs to be sent to them. We also are building the capabilities to deliver the clinical care documents, then the summaries with details, back to the payers so they can ingest them into their various systems, not their claim systems.

Another example is the need for hierarchical condition categories for risk adjustment. We can construct the appropriate data sets that payers are constantly calling the providers for and we can deliver it to them electronically. We know this because we work directly with payers and providers in their distinct workflows to be able to build these new bridges, to do it as electronically as possible within the workflows to reduce burden, reduce waste, and deliver on the Triple Aim.

What’s the timeline for delivering the product?

The first wave is going to come out in Q1 ’17. We’re working with our user groups and providers directly. There’s that preparatory. Then the orders module will come out first, followed by more enhancements that we’re going to be delivering in the RCM, followed by more and more clinical documentation and a collaboration. We’re also simultaneously building a lot more interoperability for collaboration among providers.

Everything that we’re doing from a workflow and technology perspective is being supported by a cloud-based interoperability collaboration hub and supported by analytics that are integrated as well, because there’s going to be a lot of adjustments over time.

We see this complete picture rolling out over the next three years. Based on demand and based on the number of ecosystem partners that we see, we hope to be able to accelerate that, but we want to first and foremost do no harm and create a lot of value as people have to change their business models during this very dynamic time, like none other that we’ve seen before in this industry.

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May 18, 2016 Interviews 9 Comments

HIStalk Interviews Don Rule, Founder, Translational Software

May 18, 2016 Interviews No Comments

Don Rule is founder of Translational Software of Bellevue, WA.

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Tell me about yourself and the company.

My background is in software, first at Dun & Bradstreet and then Microsoft. It occurred to me while I was at Microsoft that the ability to digitize biology through sequencing is something that’s going to be very important to healthcare. I spent a lot of time thinking about it there. When I left Microsoft in 2008, I spent a year in a genetic testing lab and realized that just about every lab is going to be interested in genetic testing, but the ability to understand the implications of those tests is not readily apparent.

You’ve heard of the $1,000 genome and the $100,000 interpretation. Getting the cost of that interpretation down is critically important. That’s what we’re focused on. Having looked at all the different shiny objects we could follow, we focused very much on pharmacogenetics because we feel pretty strongly that that’s going to be the first and most pervasive use of precision medicine.

How often do genetic test results change a physician’s mind about prescribing a given drug?

Something came out from Mayo Clinic recently that said if you look over all the potential mutations that there are, the vast majority of people have some mutation that will be actionable at some point in their life. In terms of a specific individual, it’s a little bit skewed because often they don’t get tested unless there’s a suspicion of a problem, so we know we have a sampling error here. But I would say at least 60 percent of the time there’s something that’s actionable.

That patient’s genetic predisposition could mean that a given drug might be entirely inappropriate, or it could be that the dose that would otherwise be chosen might be too high or too low, correct?

That’s correct. For example, 20 percent of the population doesn’t metabolize Plavix well. But if you put together a collection of drugs — and it’s not uncommon that people are taking anywhere from five to 15 drugs — across that collection, it’s pretty common that there is something that you would either adjust the dose or you might look for an alternative on the basis of the person’s metabolism and other factors.

Can you correlate a patient’s new genetic testing results against their old medical history to learn something new, like why treatments have failed or that doses were inappropriate?

Forensically, looking at somebody’s metabolism is not uncommon in trying to understand the cause of adverse drug effects. The most famous case was in Toronto. A woman who had just delivered was given codeine for pain. Four days later, her baby died. It turns out she had multiple copies of the gene that metabolizes codeine into its active form, which is morphine. She instantly processed that codeine into morphine, it was expressed in her breast milk and the baby died. It was only through that sort of forensic analysis that they understood what was going on there.

Are drug companies going back to look for genetic reasons their products may not always work well?

Absolutely. In fact, even some of the development pathways they’ve taken have mitigated away from the cytochromes that they know are variable in different people, or at least mitigated toward different cytochromes. From the CYP2D6 or CYP2C19 that they know are altered in many people in the population, they’ve moved to drugs that are CYP3A4 and CYP3A5 and potentially killed some drugs that would be very beneficial if you could understand who in the population would benefit from them.

Can they determine that genetic influence in the lab while developing the drug or do they have to wait until the drug is rolled out to a broad population to see what happens?

That’s one of the reasons we think pharmacogenetics is going to be so compelling. There is a lot of good data about how drugs that have been approved are metabolized. The FDA, for a very long time, has required studies that show exactly what genes are in effect at the time it’s metabolized to get an idea of what pathways clear it and, to a lesser extent, what pathways are affected by the drug.

As a company, will you stick to pharmacogenetics or expand into other areas of personalized medicine?

There certainly will be others. We look at ourselves as more a platform for genetic analysis. Pharmacogenetics, again, we think there are hundreds of millions of people that could benefit from it and the data is well understood because of the FDA and other studies. But we have begun to broaden. We have a cystic fibrosis panel that’s coming out. We have some other infectious disease that we’re looking at for later in this year, as well as some licensing around functional medicine. There are lots of areas that it’s applicable to. But again, we see pharmacogenetics as well proven, very important to the clinical process, and readily available.

Does the decreasing cost of genetic testing justify having it done just to guide drug therapy decisions?

One of the transitions that the industry will go through in the next couple of years is from reactive to proactive. Right now, it’s common to get a genetic test when you think you’re going to be prescribing Plavix. You’ll see what happens, what is the viability of Plavix, because there are other alternatives, but they’re much more expensive.

What we see happening over time is beginning at hospitals like Inova, where they get the test early in life and keep it in the medical record. From that point on, for the rest of your life, anything you get prescribed, you can at least check it to see if there are genetic determinants of the efficacy or toxicity of the drug. You can make decisions on that basis. The real key there is building that into your clinical decision support in such a way that the physician can make use of that test throughout the future.

Is only one lifetime test required for a given patient to determine not just the pharmacogenetic influences that have already been documented by research, but also those that might be discovered in the future?

There is one broadly relevant test that would be relevant to, say, 180 drugs. There are a few a little more specific. For example, specific drugs for HIV,  there might be a gene that’s fairly difficult to test that would be relevant to that, so you might do a reflex test if you’re considering Abacavir for a particular patient. Certainly there are panels now that cover the vast majority of the drugs that are known to have important genetic effects.

Other than the patient, the beneficiary would seem to be insurance companies that can avoid the cost of ineffective therapy or the treatment of genetically driven therapy complications. Are they willing to pay for the testing?

They are willing. There’s a big challenge right now, though, in reimbursement. If you’re a pharmaceutical company going in to get a new drug approved, you can afford to spend for a gold standard clinical trial for it. In the world of a diagnostic, where the drug may be off patent for 20 years, diagnostic companies don’t have the same returns as drug companies. Even once they’ve produced the evidence, they can’t necessarily patent that evidence, so it might be available to all their competitors. The evidence creation has lagged behind.

In fact, there’s a really challenging dichotomy now between NIH and FDA. They are pushing forward in precision medicine and CMS is pushing back. That’s a difficult place where the industry is in right now. We really haven’t figured out how to get beyond that.

What is especially interesting about that, though, is that we’re beginning to see some forward-thinking payers who are willing to run tests themselves, who are willing to run trials themselves, to see what they could potentially save by putting pharmacogenetics in place. They look at it as a competitive advantage to lower their costs relative to their competitors.

What information from your system do Inova’s clinicians see in Epic?

At this moment in time, what they see is a static report. The evolution that we see in the future is that we can provide, in that static report, the information that’s relevant to the physician at the time they’re ordering the test, but then make the rest of the data available in the EMR as clinical decision support for other decisions in the future. That is certainly a vision that we all share. We’re early on in the implementation of that.

First Databank is distributing your knowledge in their reference content that drives order guidance and alerts from vendor clinical systems. Will that make your information more easily used and widely available?

That’s exactly the approach we’re taking. We’re working on providing what we have, making it available available through a standards-based API so that anyone — whether it’s a pharmacy system, an EMR, an application in an EMR, First Databank, or someone who works with the payers — can plug into our system and say, "Should this person be tested on the basis of the drugs that they have? Where should I order the test from? Once I have the results of that, can I go back and re-query it on the basis of some new set of drugs or some prescription change that I’m doing in the future?"

Where do you precision medicine going in the next five years?

There are a couple fields to look at. Cancer is pretty well along now. There’s a lot of work going on and that will be pervasive in the next five years.

It  takes more parties to put pharmacogenetics into place, so I think in the next five years, we will see the majority of forward-thinking organizations incorporating pharmacogenetics into the prescribing decision factor.

For things like heritable disease, the interpretation and the understanding will be so readily available that for many of the things that are diagnostic odysseys now and many of the things that are rare diseases that are heritable, those will be much, much easier to find in the future, much easier to understand.

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May 18, 2016 Interviews No Comments

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