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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

HIStalk interviews Bill Van Wyck, President, Zillion

May 16, 2016 Interviews No Comments

Bill Van Wyck is president and chief innovation officer of Zillion of Norwalk, CT.

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Tell me about yourself and the company.

I’m the president and chief innovation officer of Zillion. We are a technology platform that powers digital healthcare products that are redefining engagement with consumers. It’s allowing healthcare providers to standardize and deliver better care to consumers outside a facility.

What can customers do with your product?

Companies all across various types of healthcare stakeholders are using Zillion’s technology to deliver three main areas of care in the form of digital programs. Preventive care, like medically necessary weight loss to pre-diabetes type programs. Care management and disease management for more chronic conditions including diabetes, smoking cessation, and depression. The third category is procedural care – bariatric programs, including pre-conditioning and post-conditioning, post-surgery, prenatal programs, and even in orthopedics for knee replacements and shoulder replacements.

Many software companies want to be involved with patient engagement. Where does Zillion fit in?

Zillion has approached the healthcare vertical from a technology perspective. We look at the combination of services and look at the industry jargon around point solutions such as telemedicine, telehealth, population health, and so on. We look at that more from a configuration standpoint and a software technology standpoint.

The differences in the market exist where healthcare has been trying to build vertical silo products to address specific conditions. The reality is that patients don’t typically have just one condition. They are overweight and may have depression, or they may be diabetic and need other types of procedures and support. There are co-morbidities and multiple chronic conditions that exist in the real world.

Having a common backbone platform like Zillion where you can design, create, and deploy programs to patient populations and then refine and refine and modify those programs at scale is a differentiator for healthcare stakeholders. When you look at what they’ve been building, typically none of them interact with existing systems. They’re not interoperable. They don’t always reach patients on the devices and the technology that they use day to day.

Can patients customize the view they’re given? If I have both COPD and a heart condition, is the presentation seamless?

To play that back, the patients don’t configure the content or the availability of services on the platform. The clinician, caregiver, provider, or the payer are configuring and designing best-in-class programs based on evidence-based care plans. It’s keeping the doctor in the process. 

That’s where Zillion is highly differentiated. The industry has focused a long time on these member portals and wellness portals, configurable portals which are largely self-serve. In the real world, if you’re going to drive outcomes, standardize plans, and offer compelling services that impact behavior, you need to keep he caregiver in the process. You need to keep best-in-class content programs delivered and designed by professionals.

We look at it as an iceberg. The tip of the iceberg is the member portal. Everything below the water includes coaching portals, program administration portals, practice-based on-boarding portals, as well as administration portals that allow the population of caregivers to work together to serve and benefit the patient. It is served up to the patient in a whole new way.

My question really was that if I’m a physician and I’ve ordered weight loss content for you and then you have a heart attack, can I just turn the heart attack content on and you start seeing it within your existing presentation?

That’s exactly correct. You can add content, augment content, and even assign and augment services in the form of types of caregivers and credentialed clinician and make those available to patients depending on their needs.

Who is your typical user user? What parts of your platform can be used out of the box without creating original content?

In terms of who is using this as a patient or a member, typically the payers are targeting self-funded employers, typically populations that have in excess of 200-300 users. They are offering products to stem the tide of chronic illness or disease within an organization.

When you look at more procedural care, you move into a different demographic. With orthopedics, you may be moving into a 60- to 75-year-old bracket, which is not in the self-funded world, but they are individuals who are being offered programs as part of a procedural care program. There it’s a different population and demographic of users.

Clients of Zillion span everything from payers to providers to specialized care practices to even device manufacturers. Depending on those types of clients, they have different levels of availability of content and plans. You look at what’s been delivered by a facility in terms of programs. You may go in for a procedural care plan for a bariatric center or comprehensive weight loss center and everything has been delivered in person with paper, quizzes, and scripts and in the form of documentation and different types of caregivers there. Zillion is going to them and taking a combination of people, content, and program cadence and bringing those together on the platform to deliver that to patients.

Some organizations have the wherewithal to create some of this type of content. By example, larger payers will sit down and build a business around a pre-diabetes program. They construct this content at a very, very high grade. Whereas if you go to an orthopedic group or a specialized group, they can use more rudimentary content. They can use more mechanical content. Move your knee this way, move your shoulder that way, do this, don’t do that. It’s less entertaining and much more practical in its delivery.

Zillion allows our clients to lay that out longitudinally, almost like an education curriculum over time. You can set up what happens chronologically across that program. What services do they have access to when? What content gets served during what week? What questionnaires and what data do we need to intake at various points along that program?

Using the combination of video conferences, content serving, IoT device integration, and so on, we can get patients to engage at very, very high rates for very long periods of time. At the end, you have better data to make better decisions in terms of modifying that program to achieve goals.

What’s the secret to not just offering a program but actually moving the needle on the health of the people who need it most, not necessarily just those who are attracted to a health tool?

There’s a shift from wellness programs to not-so-wellness programs. Wellness programs, which were typically paid for by large employers out of their benefits budget, were availability of services to help typically the 30- to 40 somethings who participate in those types of programs. The value proposition of those was largely based on absenteeism and a lot of squishy metrics that really didn’t resonate from an ROI perspective.

These organizations are now focusing on real programs that are evidence-based that include and require often real caregivers in the process. Those caregivers are in different roles these days, everything from coaches to therapists to RNs to RDs to actual doctors. Using different combinations of those and doing it in a scaled way drives better behavioral change than you could ever do with self-service apps.

Zillion is powering those next-generation digital products by combining those video communications apps with digital workforce scheduling with content management and servicing and data analytics. Bringing those four together to build compelling programs across those various areas I went through earlier.

Where do you see the company moving in the next few years?

We’re going to continue to build out the Zillion platform as a service. It is the underlying backbone for all the programs that run on Zillion. Zillion will look to add multiple programs and platform-level services and integration that make the product more and more valuable and relevant to broad-scale healthcare products. We look to build out as many programs as we can for our clients on our platform.

We are a software technology company, so we focus on driving utilization of our platform. A clarifying point is that we do not brand any product Zillion. We build products quickly for our costumers and configure them quickly for our customers which are branded under their names, using their content and their care practices.

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May 16, 2016 Interviews No Comments

HIStalk Interviews Cliff Bleustein, MD, CEO, Computer Task Group

May 11, 2016 Interviews No Comments

Cliff Bleustein, MD, MBA is president and CEO of Computer Task Group of Buffalo, NY.

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Tell me about yourself and the company.

I’ve been very fortunate to have broad-based experience in business, across healthcare IT, consulting, and international. In the clinical realm, I’m board-certified in urology. I have a license to practice medicine. I saw patients in private practice. Academically, I’m an adjunct professor in healthcare economics at NYU Stern School of Business. Prior to that, I was a clinical assistant professor in urology. I also have a research experience, with more than 20 peer-reviewed publications, a couple of patents, and several awards.

With respect to CTG, we’re excited that we’re celebrating our 50th anniversary of providing industry-specific IT services and solutions that address business needs and challenges of our clients in high-growth areas in North America and Western Europe. One of our largest industries is healthcare, and next year will be our 30th year in healthcare.

In North America, we provide offerings that span needs for improved IT and data analytics. We deploy and optimize electronic health records. We work for cost-effective IT operation support. We also have CTG North America, our strategic staffing services for technology companies and large corporations.

CTG’s share price has dropped 40 percent or so in the past year since the company hired you for your first CEO position following the death of your predecessor. What pressure do you feel from that and what steps are needed to get the company back on track?

I’ve been very fortunate in my career to have had several opportunities to lead large teams of global scale. CTG is another team of very capable individuals that span a broad base of capabilities.

Certainly being at a public company offers new challenges in terms of managing investors, managing a board, and managing analysts. Any time a company has any transition, there are always challenges in managing through that.

Having said that, yes, our stock price has been down, but we are already beginning to see some encouraging signs that the market is accepting a lot of the changes that we’ve done over the last year or so. We’re excited about the initiatives that we have in place. We’ve invested in doubling our healthcare sales force. We’ve added four delivery leaders. We added Al Hamilton, who leads our healthcare group, last year. We’re well on track to selling our services and offerings to the marketplace.

Where do you see the consulting and staffing business going now that we’re on the downward slope of EHR implementation work?

Nothing helps industry like a federal mandate which is followed up with funding. I agree that everyone had anticipated a significant upswing.

What you’re seeing in the industry now is a movement back to what are going to be normal levels of spending across organizations as they prioritize what their legacy applications and systems are and the new and emerging systems that they need to be competitive into the future. This year has been more of a normalization of spending from one-off IT initiatives that were inspired by the Affordable Care Act.

How are contingent work forces being put in place?

When you look at the staffing industry as a whole, it is very clear from other consultancies, such as staffing industry analysts, that as organizations get bigger — meaning moving from less that 10,00 employees to middle-market, which is 10,000 to 50,000 ,and larger companies, which is more than 50,000 employees — that the likelihood of organizations putting in a vendor manager system or a managed service provider goes up, from roughly 50 percent to greater than 80 percent for the larger organizations.

If you look at healthcare in general — across payer, provider, life sciences, and even in physician groups — they are merging to get scale at a very rapid pace. The likelihood of these organizations, as they become much larger, for them to put in some form of manage service provider or vendor manager goes up dramatically. With the implementation of those, the likelihood that these organizations are going to be contracting with their vendors through a staffing model goes up dramatically. The number of vendors who eventually are able to service these larger industries goes down, as most vendor managers try and consolidate the number of approved vendors.

We’re expecting the number of organizations to implement these forms of contracting vehicles to go up and the amount of contingent hire, staffing hire to go up as well. Most people who are purchasers of services right now in the industry are predicting that they are going to increase the number of contingent hire workers as well who don’t have to sit on their balance sheets and who overall are easier to add on, or when projects are done, let them go on to their next project.

What kind of help are health systems asking for?

A lot of what we’re seeing has to do with the mergers that are occurring in the industry. One of the major trends we’re seeing is the need for legacy application support. Organizations are constantly challenged with trying to provide all of the resources that their lines of business leaders need. That means a constant balance between managing systems that they currently have and adding new capabilities that they need to start managing populations, managing business intelligence and analytics, and managing some other trends that we’re seeing.

In order to effectively use them, they’re transitioning their people to a lot of the newer tools, newer skill sets, and newer capabilities while having vendors such as us manage the legacy architecture. You’re also seeing a movement, now that the electronic health records are in place, to try and optimize those systems within each of the hospital systems. You’re seeing a movement to improve their revenue cycle and the workflows associated with that. You’re seeing a trend toward the movement of these systems towards individual physician practices.

Vendors seem to be flocking to population health management in looking for their next big opportunity. Where do we stand in that regard?

We’re still in the early stages. Right now, more of the industry is focused on some of the beginning aspects of collecting data around populations of individuals and are trying to start navigating the balance between living in a fee-for-service world and moving towards one where they’re being reimbursed for value, and trying to understand how you can manage a population of individuals for which you are responsible, but may not be fully integrated within your health system.

Now that data has been digitized, and now that systems have the data and are collecting more of it every day, they’re just starting the beginning stages of understanding how these patients behave and help them manage the care that they need to stay healthy and avoid getting into the system in the first place.

Are providers struggling to understand that episodes of care for which they don’t necessarily have data are still important in managing that person’s health?

I don’t know if it’s a question that they’re not understanding the need for it. I think it’s more a question of, how do they get to all the different data elements? 

A lot of it also has to do with many of the other what are often called “non-traditional health providers” that are becoming healthcare companies and are managing these patients. You have many companies that have traditionally sold retail goods through big box stores that are now adding healthcare services. They’re looking at data differently than most healthcare systems would look at that data.

They look at transactional data that they get through credit cards. They look at purchasing behavior that they have related to all of the goods within their organization. They’re looking at histories of social media interactions that they have with these individuals and access to their social media accounts. They’re marrying all of that data to get a much better picture of how people interact and move throughout their systems and their lives.

The data feeds that we get on individuals are getting increasingly more complex and broad based. When you think about populations, it’s much more than just the interactions that any one health system could potentially have with the person. I don’t think it’s as easy as just integration and interoperability of an individual throughout the healthcare cycle, just within the walls of a physician’s office, a hospital, their payer, or any form of pharmacy or life sciences data that they have. It’s much bigger than that.

Will doctors leave the profession because of MACRA and other government programs?

I’ve had a lot of sobering conversations with physicians over the past several months. The challenge that physicians are facing is that the complexity of the regulatory environment that we have today is so challenging for most of them to manage that it’s hard for them to focus on the practice of medicine. The practice of medicine is difficult enough as it is.

That, coupled with the vastly changing reimbursement landscape, is forcing many physicians to adjust their practices in order to maintain their current income and the income of their practices to remain viable. You’re seeing a significant change in how physicians are thinking about the practice of medicine. Many of my peers who were fellowship trained in doing certain types of diagnostic tests are completely abandoning things that they were trained for and are moving towards other areas that are needed in order to support their practices.

At the same time, you hear from primary care physicians who are frustrated that they can’t maintain their current practices. They can’t stay in private practice. They’re being forced to either merge groups or join hospital systems, things that they never contemplated when they first went to medical school. 

It’s a really hard time to be a doctor today, with a lot of uncertainty, a lot of regulation, a lot of change, reimbursement changes. It doesn’t look like that’s changing any time in the near future.

Would consolidation of small hospitals and small practices be a bad thing?

To some extent, we’re going to see changes in the systems as the whole system is forced to consolidate. There are some aspects of mergers, integrations, and consolidations that are good, in the sense that it is more likely, if done well, to force individuals to hospitals that do whatever the operation or procedure that they need the best. Many things such as transplants, open heart surgery, and so forth, over time, as people do a lot of those cases, they get better. They’re more cost effective with better outcomes. That’s a good thing. 

In other aspects, the loss of some of these hospitals — certainly for many of the things that don’t require such intense levels of resources – would not be a good thing. We just have to be careful in terms in how we’re setting up the new systems that we make sure that people have access to care regardless of where they are.

Do you have any final thoughts?

We’re living in an amazing period of time where the rate and pace of change is unprecedented. The healthcare market is ripe for disruption. A lot of technologies that are coming down the pike have the potential to radically change the way we do healthcare and think about the way we do things on a day-to-day basis, whether it’s artificial intelligence, 3D printing, robotics, nanotechnology, or the use of an on-demand workforce. Many of these things have the potential to disrupt healthcare markets in ways that Uber has disrupted the transportation industries and the way Facebook is changing the way we interact. It’s an exciting time.

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May 11, 2016 Interviews No Comments

HIStalk Interviews Drew Schiller, CTO, Validic

May 9, 2016 Interviews No Comments

Drew Schiller is CTO and co-founder of Validic of Durham, NC.

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Tell me about yourself and the company.

I’m the co-founder and chief technology officer at Validic, the leading platform for directing patient-generated health data from digital health apps, wearables, and in-home medical devices into the healthcare system.

What is the level of interesting in integrating patient-generated information with enterprise systems?

The level of interest is really strong. In fact, it has been growing quite substantially over the last 12 to 18 months. There has been, in general,, a lot of questions around the usability of the data. Now we’re starting to see a lot of great use cases and examples, which is driving further interest in the market.

Is collecting the data a given and now it’s more of a matter of deciding what the business rules should be to use it?

That’s exactly correct. Getting the data from all the disparate sources is a known quantity. There are places like Validic where you can go and access data from many different sources. Now the question is, how do I get the right data at the right time in order to inform the right action to take for better patient care?

We’ve been very fortunate from a timing perspective. We started with a lot of traction in the wellness space, more the preventative health space. Now we’ve been moving in to more of the traditional healthcare system, along with patient care, remote patient monitoring programs. Also into the clinical trials space and the pharmaceutical market.

Capturing fitness tracking information hasn’t been valuable, but is the next level of maturity patient engagement and chronic disease management, to capture a more complete picture of someone’s health?

That’s exactly right. Fitness trackers are still interesting. They will become more and more relevant as the device manufacturers start to incorporate new kinds of data. For example, most of them now contain heart rate information. I know a lot of them in the future are looking toward other types of data they can collect that are more clinical in nature. But Validic also connects with blood pressure monitors, glucose meters, pulse oximeters, weight scales, a lot of other devices that can be used for chronic disease management as well.

Would the company have an interest in integrating information that doesn’t necessarily originate on a phone app, such as critical patient monitoring?

I look at the phone as a gateway or a hub. You can connect devices through that portal in a variety of ways. Through a Bluetooth connection, you can connect devices like blood pressure monitors.

We also have a product called VitalSnap that works with legacy medical devices. These are devices that people traditionally use in the home to monitor conditions like type 2 diabetes and hypertension. One of the problems that we found was that when physicians want to measure and monitor patients with these chronic conditions is that a lot of the devices that the patients were using are not connected. That’s why I call them legacy devices. 

VitalSnap enables us to grab — using the camera on the phone — a digital image of the reading from the device, turn that into a digital asset, and deliver that through our system to the healthcare provider. That enables real-time data transfer for even these legacy devices.

Where I see the industry going in general is very much toward a patient-driven, remote patient monitoring, disease management future where you’re only going into the hospital to see the provider for regularly scheduled appointments or for acute management of conditions.

What are the secrets to motivating consumers to take measurements like weight and blood pressure and then report them back?

Consumer engagement is going to continue to be a real struggle. One of the more interesting things is that we have big players from the consumer electronics space entering the health market. We have Apple, Google, Samsung, and Microsoft all entering the health market in a very real way. 

What these companies excel at is consumer engagement. There’s a real opportunity for us in healthcare to leverage the engagement that these consumer electronic companies know how to create with their consumers. We can create a more engaged healthcare consumer by leveraging the fact that maybe these consumer companies are able to engage the patients in a way we’ve never been able to before. That’s a really interesting trajectory that I see the market taking.

What do you think about Nokia acquiring Withings?

I think it’s phenomenal. It’s a sign of the maturation of the industry. Nokia was sitting there trying to understand how they could get into healthcare. Withings is a very solid, stable player in the market. They’re going to be able to do even better things with the power of Nokia behind them.

The only brands I recognize in the consumer area are Withings, Omron, and Philips. Will the big players look at what Nokia did and worry that all the good consumer digital health assets are are being grabbed?

There’s still a number of good assets out there. IHealth is a great company that does work in that space. There’s a company out of France called BewellConnect that we work with that’s really good. There are a number of newer device companies that are coming out that are OEMing blood pressure monitors and weight scales and blood glucose monitors as well. The connected health ecosystem is expanding daily. It’s certainly not consolidating.

For consumers using multiple Validic-integrated devices, would you aggregate the information or package it up in some way?

If the patient connects multiple devices for the same healthcare organization, we can certainly package those three data streams up and provide as much context around that as we can. Really we view our job as, first and foremost, being the data conduit. But then additionally, providing the ability to understand and contextualize the readings that are made available. We don’t make the decisions on the data, but we want to make the data more actionable.

What are drug companies doing with patient-generated data?

Pharmaceutical companies are really interested in collecting more data during the drug development process in order to prove efficacy of the drug. It gives them one more feather in their cap to show that the drug had a certain effect.

Another thing that’s very interesting is that there are current things going on in healthcare, such as remote patient monitoring, that can provide drug companies with new avenues for research. For example, if you have a number of hypertensive patients going through a remote patient monitoring program, it’s very possible that a new drug to treat hypertension can then be used for a certain percent of that population. You have a built-in control. You can start to see if this new drug is effective or not for these people. There are number of opportunities in the clinical trials space for digital health.

What about continuous monitoring of patients?

Patients are very willing to do things that are unobtrusive to their lives. If all the patient had to do was put something on their wrist and wear it, or put on a patch and wear it, they could go about their lives normally otherwise. They would be very interested in doing that. One of the biggest challenges that we see with consumer engagement is that we’re asking consumers to modify their behavior outside of something they typically do. That’s where we  see challenges with engagement.

What are you hearing about ResearchKit and CareKit? Will those products affect your business?

It’s not having any effect on our business. In fact, it has jump-started a number of conversations. I think it’s fascinating. First and foremost, by having the world’s largest consumer electronics company in the healthcare space, and continuing year after year now for the last three years to double down, is a huge asset to everybody who’s trying to improve patient care. It’s driving better consumer awareness, which is awesome.

In terms of ResearchKit, it’s a phenomenal jump-start kit for getting informed consent into an iOS app for a research trial. CareKit is another really interesting tool. If you are building an app for remote patient monitoring, it’s a very, very good framework for jump-starting that process on iOS.

Do you have any final thoughts?

I see Validic as fundamentally being the fabric through which digital health data flows. What we’re trying to do is become the network to act as the future of digital health. 

Where I see this industry going is that it’s not enough to just have the data. We also need to be able to provide context and be able to show the right information to providers at the right times to take the right actions. The future of our company is going to be built on is being able to provide that context.

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May 9, 2016 Interviews No Comments

HIStalk Interviews Travis Good, MD, CEO, Catalyze

May 4, 2016 Interviews 2 Comments

Travis Good, MD is co-founder, CEO, and privacy officer of Catalyze of Madison, WI.

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Tell me about yourself and the company.

My background is technology — focused specifically on cyber-security — clinical medicine, and the business of medicine. All converging in the arena of healthcare technology, which is where I’ve been for the past eight or nine years.

Catalyze is a three-year-old company that we built. The name is intentional. We help catalyze the shift within the industry from volume to value. We did it, not by building a specific type of application, but by building infrastructure that enables a thousand flowers to bloom within digital health.

How much of a startup’s efforts to get to scale are impeded by compliance or integration issues?

Obviously our thesis is that it’s a significant amount. From a previous venture, we estimated somewhere around 40 percent of product effort is spent on those two areas.

What kinds of companies seek you out and what help do they need?

It’s probably helpful to split it into two buckets. On the smaller side, there are vendors that are just getting started, signing and onboarding their first one to three hospital customers. In those cases, they’re fresh. They’re looking for a solution. They haven’t really tried that much themselves. They’ve done enough research to know that it’s something that they don’t want to try to do themselves.

The larger vendor side has companies that are pretty well established and are getting pushed by their hospital customers to integrate with the EHR. A lot of those customers have looked around. Some have tried to do it themselves using different tools and ended up coming to us because they just don’t want to manage those tools and that process themselves.

For those customers that had something in place and decided to replace it, what was the value to them of turning that over to Catalyze to manage?

With larger vendors and anybody who’s scaled beyond probably five or 10 hospitals – and we have vendors that have hundreds of hospital customers — there’s significant value at that scale in having a consistent partner, where they don’t have to tweak their application for each one of their hospital customers. Essentially, we manage the different endpoint connections for them across, 10 to 50 or maybe a couple of hundred hospitals.

They have just one consistent endpoint from Catalyze. They don’t need to do a lot of custom development on their application for each subsequent hospital that they onboard. In a lot of respects with those larger vendors and in terms of integration at scale, there’s a lot more value than at just a handful of hospitals.

What would be the challenges for a company new to healthcare to build that infrastructure themselves?

Compliance and integration raise the bar in healthcare. They’re unique to healthcare. They definitely raise the bar compared to building and selling technology into other industries.

I think that there’s two core value propositions that they get from using Catalyze. One, it is a significant amount of work from a technical perspective to set up and manage infrastructure that is secure and compliant and does things like monitoring and intrusion detection and vulnerability scanning and all of those different pieces.

Then the secondary value in healthcare is that increasingly — especially with all the recent high-profile security breaches — there’s the requirement not just of saying that you’re in compliance, but being able to prove it. Those components that we offer — intrusion detection, logging, and backup and disaster recovery — have all been fully audited and are HITRUST certified. Our customers inherit not just that technical work from us, but also the proof and the audits from us to help expedite their sales process.

Some of those breaches involved business associates. How can covered entities protect themselves better with regard to their business associates?

Those things definitely changed a few years ago with the HIPAA Omnibus rule that expanded who was covered under HIPAA and who had to participate in the form of business associate agreement. It remains challenging for covered entities because they work with a myriad of business partners, business associates, and vendor customers or partners. The major challenge is that business associate agreements aren’t really standardized. Comparing business associate agreements is an additional level of work. Covered entities have to deal with that across all of their partners and business associates. That is a challenge for them.

A lot of large payers have standardized on HITRUST as a framework and as a more true certification, which goes beyond the business associate agreement. It certifies a lot of the different technical pieces and organizational requirements of HIPAA. It standardizes it across NIST, PCI, and a bunch of other frameworks. To expedite that process — not just through these business associate agreements, but also to assess the security of a partner or business associate — HITRUST is becoming the accepted standard in the industry.

Will we see more componentization or segregation of technical capabilities as cloud-based systems extend the functionality of EHRs?

Two or three years ago, every answer was, “Our EHR vendor is going to get around to it." Increasingly, that has changed. It has opened the door to telemedicine solutions, bundled payment platforms, and clinical communication solutions. All these other tools. 

The same is true of interoperability. CommonWell was announced. FHIR has been in the works for some time now. Increasingly, EHRs have not made it any easier to integrate. If you don’t have this middle layer, this componentry,  every company ends up reinventing the wheel. That is incredibly inefficient, both from the company’s perspective as well as from the hospital or health system’s perspective.

Increasingly, there is a need for that middle layer. There is a need to secure that connectivity and standardize it from the EHRs to the digital health tools, solutions, and services that are increasingly serving healthcare customers.

Healthcare is not unique. A company called Clever in education frees data from educational systems and standardizes it so that health applications can be created and distributed for schools. Healthcare is in need of much of the same thing. EHRs have been too slow to cover those things themselves. They’re not meeting the timelines that now the government has mandated things like MACRA and MIPS. There is a need for that middle layer componentry.

Are EHR vendors still trying to protect their own interests or are they now open to the idea that customers need third-party solutions?

Healthcare customers are demanding it. EHR vendors like Athenahealth have been out ahead with their More Disruption Please program in terms of creating an ecosystem. Increasingly, healthcare or EHR customers are demanding it. You saw the trend where consolidation on a standard platform was the epic stage of growth in the industry.

Now as we shift, we see new technologies coming into healthcare to deliver value that is needed by the health system customers. I mentioned some examples like bundled payments or virtual care solutions that then direct people to the appropriate levels of care and reduce costs. All of those different pieces.

Those are things that health systems desperately need to start implementing across increasingly large portions of their population. They are now saying that the EHRs aren’t necessarily going to get there. It’s not that EHRs aren’t going to remain the hub of clinical data and the hub of clinical workflow within the health system, but we will increasingly see these EHR add-ons, digital health solutions, and ecosystems.

Kaiser has already tested, piloted, and is starting to scale a lot of different solutions. Kaiser is a little bit different,  but it does reflect the direction the industry is going. I think we’re going to see a lot more with a lot more health systems.

What challenges will vendors experience in trying to open their systems up with APIs?

They should look at standards like FHIR. It’s gaining a lot of interest and "adoption," quote-unquote. “Adoption” because it’s  hard to find FHIR in the industry that’s actually implemented in production. Looking at something like that is probably a good guidepost for how to think about enabling access to your EHR. Cerner and Epic are the two big beasts, but increasingly, practice-based, specialty-based, all these other EHRs need to also be thinking about it. Looking at something like FHIR is probably the right approach. At least from the organizations that are promoting FHIR, it seems to meet the requirements in terms of accessing EHR data.

What have you learned from creating a company?

One of the biggest things is saying no and not pursuing certain things. When you look at healthcare, there’s a lot of opportunities and a lot of things that seem broken, inefficient, not optimized for care, and all the things you assume healthcare should be built around. But you can very quickly go down a rabbit hole if you don’t have focus. 

A second thing is being  very open about what you’re doing, even if it’s early stage. Getting feedback, finding mentors, finding people at organizations that may be customers down the road, getting their feedback. Not being too what people call "stealthy" or a "stealth" type of startup, but being open about what you’re doing. 

Success is ultimately going to come down to execution. Scaling a company is going to come down to execution. You have to be much more open about the idea and what you’re doing if you want to be successful.

Do you have any final thoughts?

Having spent time at HIStalk writing about digital health and companies that were building solutions for the next wave of healthcare and then jumping to the other side of building a company that then helps those vendors and those different technologies of scale has been incredibly exciting. I get to work with a lot of companies that I used to write about and I was excited to see their history.

The industry has moved much faster than I expected in  embracing these digital health solutions and EHR add-ons. It’s exciting to see some of these digital health solutions start to scale and then get research and data about how they actually work. It’s very, very cool.

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May 4, 2016 Interviews 2 Comments

HIStalk Interviews Michelle Holmes, Principal, ECG Management Consultants

April 20, 2016 Interviews 1 Comment

Michelle Holmes is a principal with ECG Management Consultants of Seattle, WA.

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Tell me about yourself and the company.

I am a principal with ECG Management Consultants. I’ve been with the firm for about ten and a half years. I’ve worked in healthcare since 1993 and have been involved in healthcare IT specifically since 2003, which was when I was involved in my first EHR implementation.

ECG is a healthcare consulting company. We focus on providers and payers, specifically. We’ve been around since 1973 and have services in technology, operations, finance, and strategy.

How actively are health systems buying physician practices or affiliating with them in creative ways, and how are tighter linkages between health systems and practices affecting quality and cost?

I wouldn’t categorize it as an emerging trend. It’s a trend that we’ve been seeing for quite a while now, which is various forms of consolidation. Whether it’s acquisition or some other type of affiliation, the number of independent physician practices is reducing in size and the number of independent hospitals is reducing in size.

A lot of that has to do with efforts associated with improving quality and also containing costs. Reducing redundancy out of the system, whether it be from a personnel perspective, a technology perspective, whatever the cost basis might be in that regard. Also taking the things that the individual organizations do really well — in terms of service lines, specialty care, etc. — and proliferating that across a broader network of providers to try to increase the quality for that provider base up to a higher bar than what was previously variable from group to group to group.

Are you seeing any new urgency on the part of health systems to look harder at their costs since they are responsible for a lot of overall healthcare expense?

With the transition from volume to value, it’s essentially becoming a business imperative that they do that. Whether that includes acknowledgement that they they were part of the problem, or they see that now is the opportunity to focus on that and to act on that because it’s a requirement if they’re going to be sustainable and maintain any type of margins because of how the payer environment is shifting. Either way, the focus is there. You see cost control measures, but you also see a shift in care out to the ambulatory environment just to reduce the higher-cost acute care that tends to result in the larger bills.

Are hospitals prepared to be more responsive to their customers or patients than they’ve been in the past?

It’s highly variable in the market. You see some organizations that have led the charge on that and have made it a competitive advantage for themselves within their respective markets.

If you look at, for example, the portal adoption rate for Kaiser since they launched their portal in the early 2000s and had that focus, that’s become a mainstay of their business and has helped them to be competitive in many environments where the consumers have multiple options, in terms of insurers, but overall network providers. Then you see other pockets of the country that aren’t thinking that way at all yet. There is a ton of variability there.

For some payer and provider organizations in the country, you’re seeing entire consumer technology divisions being created and being supported with capital and operating dollars. To have the patient be more at the center of the decisions that are being made and do internal investment in consumer technologies, versus just waiting for the broader IT industry to necessarily catch up in some cases.

What is worrying academic medical centers right now?

The AMCs have a lot of the same pressures as other organizations, but then they have additional requirements that are put on them, whether it be research, their GME programs, or where they get their funding. They have their own concerns as everyone else, but they have a lot of additional challenges and requirements that they have to work through that make it much more difficult to figure out how they’re going to allocate funds and where they’re going to receive funds from.

You also see academic medical centers that have had a distributed group within them, separate sets of clinics that were operating fairly independently and they’re trying to create more of an integrated group within themselves to try to lower the cost basis, but also try to take out the variability from area of care, whether it’s department to department or specialty to specialty. To your point earlier, they can also look at the cost and the quality basis that they’re working from at the same time. 

They have to handle all that at the same time that they’re dealing with the challenges of operating a school of medicine, operating a school of nursing, looking at the research requirements, providing faculty oversight, running GME programs, et cetera. It’s a lot to handle.

It’s been said that we’ve laid the technology tracks and are now realizing what we can do with newly collected healthcare information. What ideas are out there?

In terms of Meaningful Use, it definitely got systems in environments of care where it didn’t exist before. Areas of the hospital, clinic, or whatever that were largely paper based. It did push a lot of organizations to at least get some digital storage. Did it get all of the benefits that were touted at the time? I personally don’t think so. I think a lot of people don’t think so either, in terms of it being the magic bullet that it was marketed as, to improve care and improve safety. As people have these systems, whether they be expensive systems or lower-cost systems, in their environments now, they’re seeing ways that they can optimize those systems so that they’re using the data to make better decisions.

A lot of the other benefits in terms of efficiency, I don’t think that we’ve seen those. The usability of most of the systems, especially on the clinician side, hasn’t been there to allow more efficient work flows. They’re looking at ways that they can use the information and system to make wholesale different decisions about how they’re going to run their organizations, versus just appending that, they plug the system in and it’s going to make cappuccino for them, for example, and do all these wonderful things. They’re going to have to make more transformational decisions about how the organization works on a day-to-day, week-to-week basis. If they can make some of those decisions based on what the data is telling them, at least they can be more directive in what they’re moving toward 100 percent reactive to whatever the latest firefight is.

What will the impact of the CPC+ program be? Do you see CMS wanting to become more involved with how EHRs are used?

Moving away from just the rules and regulations associated with Meaningful Use is allowing the vendors to put more of their R&D dollars in some of the stuff that matters more so in terms of how systems are used within environments of care and that usability factor that’s going to drive efficiency and adoption that actually results in these types of outcomes. I think CMS putting some focus on programs like this, as opposed to, “Which buttons are you clicking to produce which reports?” so that you can satisfy the requirements of a given stage and avoid the penalty for not complying with those stages — we’ve gotten a little bit of that behind us.

By having more quality-centered programs like this announced, it’s going to further help align the interests of the users of the systems and the makers of the systems so that those development dollars are going into things that can help the providers, help the hospitals and clinics, and ultimately and ideally, provide some efficiency and care outcome impact as well.

The nice thing about these programs is that they do emphasize the fact that there’s a lot in these technologies that people put in in the Meaningful Use era that they just haven’t really used yet. They were using the basics of it, whether it be decision support or outreach to patients for reminders, et cetera. They were using it to hit a numerator and a denominator without as much line of sight on what the impact of that could be or should be.

Programs like this one are a good reminder that you have a lot of tools at your disposal already. If you narrow your view and just try to move the needle a little bit in a couple of these areas, you can get some benefit out of them instead of trying to hit a numerator number just so that it looks right on the report, but not necessarily seeing what value that’s providing to your patients.

Do you have any final thoughts?

It’s an exciting time in the industry because organizations are  focusing on IT as a strategic enabler of other outcomes or directions that they want to move, as opposed to IT and IT investments as a standalone decision that they have to do or that may only be linked to the financial side of the company or the organization.When I first started implementing EHRs, it was really common that the IT director, or even CIO, reported up through the CFO, for example, and didn’t necessarily have an equal seat at the table with those making decisions. We’ve changed a lot of that in the last 10 years.

Organizations, especially now as they’re looking at how to optimize their systems and, more and more, if they need to replace their systems and how they need to replace their systems –  that’s a much more coordinated and collaborative conversation with strategic drivers, financial drivers, and clinical quality drivers. You have your IT leaders saying, "We’ll help enable whatever the best thing is to support those other goals and initiatives," as opposed to having more of an IT decision or an IT implementation in a silo, where we hope that we get those other benefits and we definitely hope that we don’t introduce harm or a step back in those other areas of the organization. “We’re going to do this with the intent of improving those areas and measure our success as to whether or not we did that,” versus measure our success on, “Did we get everything turned on at the time that we said we were going to flip the switch and within the capital budget that was given to us as part of our implementation?”

For me as a consultant, it’s a lot of fun right now. We’re doing this and we’re actually seeing some of the outcomes from what we’re doing, as opposed to, we’re doing this and we’re trying to get really excited about a go-live event, not knowing whether or not that go-live event is actually going to lead to anything meaningful in terms of real outcomes on the care and safety side, or on the cost control side.

For a while there, it was a bit of a sludge getting through healthcare IT consulting on a day-to-day basis, where it was so focused on go-lives and numerators and denominators. We took a step too far away from why it is that we got in this business in the first place. Now we’re getting closer to some of those original projects, at least in philosophy and emphasis, where nobody was making us do it, but we did it because it was the right thing to do. For me, my job is a lot more fun, over the last 18 to 24 months even, than it was for the few years before then.

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April 20, 2016 Interviews 1 Comment

HIStalk Interviews Ben Moore, CEO, TelmedIQ

April 18, 2016 Interviews No Comments

Ben Moore is founder and CEO of TelmedIQ of Seattle, WA.

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Tell me about yourself and the company.

We’re a healthcare IT company focused on improving communication between clinicians to save time and increase patient safety. We do that by supplying HIPAA-compliant texting and voice solutions that integrate with the clinical systems in the hospital. We work with over 300 healthcare organizations to improve communication for close to 80,000 clinicians every day.

This company was started based on personal experiences within the healthcare industry. More specifically, my wife was in the hospital with a complicated pregnancy with the arrival of my daughter. I noticed a lot of issues in the communication between providers, specifically when patients were being handed off between doctors and nurses. That inspired me to start the company to fix that problem.

Into what groups would you categorize your competitors that offer pager replacement and secure messaging?

The first-generation, basic solutions take text messaging and secure that channel. The majority of the vendors fit into that space. There’s not really any efficiency gained by those solutions. There’s no clinical work flow. They don’t solve any of the fundamental problems. They just secure a channel that’s already being used. That’s the largest quadrant.

One step up from them are systems that attempt to do some integration with other systems, such as the call center and physician schedules.

The more strategic vendors are the ones that have robust, bi-directional integration with the medical record as well as work flow concepts.

The other component here is voice. Voice still drives between 30 percent and 50 percent of all communication between clinicians. You can also segment that out by which ones offer voice and which ones do not.

Sometimes technology vendors don’t understand that pagers offer value over telephones because they are asynchronous, which prevents busy clinicians from being interrupted. Are some vendors good with the technology but not all that aware of optimal clinician use?

Secure texting solutions give you that asynchronous approach, but it’s always been our belief that they’re not enough to replace pagers. We think it’s a dangerous context for an organization to try and replace pagers with texting. Some examples, such as who should get Dr. Smith’s messages when he’s unavailable? What happens if a page is not responded to in five minutes? Secure texting solutions don’t address those issues.

Pagers are more reliable than a smartphone in the sense that they are able to penetrate to the bowels of a hospital. It’s not enough just to say we’re going to replace pagers with secure texting. You need policy and rules behind how those messages get delivered.

The other thing that you need is voice capability, so you can call a pager number and leave a message. Secure texting platforms don’t do that.

How do you see the convergence of communications devices or services in healthcare?

There’s a few issues with respect to the secure texting solutions today. A lot of hospitals will buy them and layer them on top of other systems. It’s just one other mode of communication. Adding another secure texting platform to existing nurse mobility, house phones, and pager devices is not enough. It just adds to the clutter.

Our vision is of a single solution that coordinates all of those device end points. We’re calling that a healthcare communications hub.

As far as clinical integration, when you look at EMR platforms, when they’re used properly, they do a good job at clinical documentation. Some of them do an OK job at clinical work flow. But there’s a lot of things that need to be communicated between providers that should never go in the medical record, and some things that should. That’s one of the problems that we’ve tackled as a company.

For example, even a secure texting platform is not appropriate for the texting of orders if you haven’t thought through how those orders would make their way back into the medical record.

Are you taking situational awareness from the EHR and sending out alerts?

That’s one of our fundamental work flows. We have a deep level of integration with not just the EHRs, but also the lab systems.

We have a policy engine that allows the organization to set thresholds. For example, if a critical patient value comes back and it’s not read or accepted or reviewed by a clinician within a certain period of time, escalations can occur. That does two things. It improves your clinical efficiency by not requiring, for example, a physician to repeatedly log in to check for test results in the EMR. But it also fulfills the Joint Commission requirement to have escalations on critical lab value delivery back to the requesting provider.

What you said is exactly on point. That’s really where this industry is headed, which is situational awareness-based. Not just on the medical record, but also on the physician’s schedules, the time of day, and other policies that affect patient care.

What are the challenges in making the conversion from a hosted pager infrastructure to Wi-Fi or cellular?

It’s less of a problem now than when we started the company five years ago. You have corporate Wi-Fi that’s been put in place for the support of telemetry applications in healthcare. You can leverage a lot of those networks for the communications network.

What happens when the message does not get to the end point? That’s where you need a system that identifies that scenario and can respond on it through escalations or try an alternate delivery of a message. That’s an area that we were focused on from the beginning of our company. We productized that with our first launch called SmartPager. That’s exactly the issue that we addressed initially.

Is it now assumed that employees will use their own devices or are health systems buying devices for them?

What we’ve seen now as the norm is a mix of the two. It’s divided based on the type of clinician.

In the majority of our clients, the physicians are using “bring your own device” based on their preference. Some physicians are using corporate devices. But almost ubiquitously, all the nurses and other clinician staff that are on the communication network are using it from a corporate device.

It’s obviously important to have a solution that works nicely in that “bring your own device” environment, but that can also support a corporate device scenario. I believe that’s going to slowly evolve, where nurses will start to get more into the “bring your own device.” But right now, typically the policy for nurses would be corporate devices accessing through, for example, the nurse workstation. It’s not very common to see a “bring your device policy” for nurses. In fact, I haven’t seen that in my five years.

Are health systems interested having patients securely message into the health system with enough system intelligence to route their messages correctly, such as for population health management?

Yes. That is one of our initiatives, to allow patients to be a part of the communication platform.

Our experience when we tried to launch that initially was that it’s almost impossible to reliably get patients to install an app. Where we’ve taken the product — and where I believe the industry will go — is it will be a mobile Web experience that has a very similar experience to an installed app. That’s the best way to drive patient adoption, to not require them to install an app.

When the patient communication comes back in to the healthcare network, it has to be triaged based on who that message should go to and based on the call schedule and availability of the providers.

How does an answering service fit into the communications suite?

Our answering service essentially extends what is already being used as the texting platform and turns it into a converged solution. Clinicians can use one application to handle all of their texting and voice calls.

On my iPhone, if someone sends me a voice mail, I have no way to share that voice mail with a colleague. I’s the same thing for clinicians.Our solution allows voice mails to be passed around as they were text messages to allow for better communication. A lot of HIPAA audits overlook the fact that voice mail on personal devices is not secure and not being governed by the organization. By using a platform like ours, you can lock down not just texting, but also the voice mail communications between providers.

Where do you see the communications spectrum evolving over the next several years?

Things will be consolidating into single platform that involves all the stakeholders. Right now you have companies focusing on physician communication and others on patient-to-doctor communications, patient-to-practice communications, and nurse call communications. There’s no reason that can’t all happen on one platform, But in order to accomplish that, you need the clinical expertise, the integrations, and the experience of being in the market for a number of years.

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April 18, 2016 Interviews No Comments

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