HIStalk Interviews Joshua Mandel, MD, Harvard Medical School

Joshua Mandel, MD is on the research faculty at Harvard Medical School and is the lead architect for the SMART project collaboration between HMS and ONC.

Tell me about yourself and your job.

I am on the research faculty at Harvard Medical School. I’m in the department of biomedical informatics there. I work on making it easier for patients, clinicians, and researchers to work with electronic health data. I got there via medical school, where as a medical student I realized there was a lot more that computers could be doing for us than they were doing.

Describe the SMART project and how it relates to FHIR.

SMART Health IT, which is an acronym for Substitutable Medical Applications and Reusable Technologies, is a project that was originally sponsored by the federal government, by the Office of the National Coordinator for Health Information Technology, with a goal of building an app platform that allows third-party apps to plug into various kinds of health information systems. We specifically focus on apps that plug into electronic health records, which might be apps that clinicians use, apps that plug into patient portals, personally-controlled health records the patient would use, or apps that plug into data warehouses that researchers might use.

The goal is to provide apps with everything they need to be able to present a consistent user experience. The apps shouldn’t have to know about all the internal details of each different health IT system. The goal is to abstract the apps from those details. That’s the high-level goal of SMART.

We use a number of technologies under the hood to make that work. We use a set of open technologies everywhere we can. We use an emerging specification from HL7 called Fast Healthcare Interoperability Resources, or FHIR, to provide the data layer of access. FHIR gives us a set of data models and it gives us a Web-oriented REST API that application developers can use to query an electronic health records system for data.

Then on top of that, we layer a security model using OAuth 2 and OpenID Connect so that users can sign into apps using their existing accounts so they don’t have to create a new account for every app they want to use. That includes a permissions model, so you can give apps access just to the data that they need and you don’t have to give apps access to everything in your system.

We wrap all that together with a little bit of glue so that we can actually plug these apps into, for example, an electronic health records system. You might be a clinician working with an EHR system from Cerner, Epic, or any number of vendors beginning to implement these specifications. When you’ve got a patient record open inside one of these systems, you can launch an app and it knows about the context of what you were doing inside of the EHR, so that app can launch directly on the patient that you already have open and help you get some new jobs done that the original EHR didn’t have any functionality for.

How will that be positioned against vendors who have declared themselves to be open and created their own equivalent of an app store or an ecosystem with partners that they’ve approved?

We’re seeing interesting trends from the electronic health record vendors towards allowing certain kinds of third-party tools to integrate with these EHR systems. There’s still some big, open questions about the extent to which we’ll see standards as the basis for that integration versus vendor-specific data access.

We can actually separate out two questions. One question is, what are the technical mechanisms by which the access works? Are we using standards like FHIR? Are we using vendor-specific APIs? That’s the technical piece of it.

Then there’s a policy piece. Regardless of whether you use standards or whether you use vendor-specific APIs, there’s a policy piece about which apps are going to be allowed to talk to a given system and how are vendors and healthcare provider organizations together going to control that access.

What levels of capability or interest in SMART are you seeing from the three significant inpatient EHR vendors?

Overall, the goal of SMART is to provide an interface where apps can plug into outpatient systems, inpatient systems, and various other kinds of health information systems, including health information exchanges and researcher-facing systems. We don’t have an exclusive focus on the inpatient world, but of course it is an important area.

We’ve been very encouraged over the last few months by the participation of a number of the big EHR vendors in a project called Argonaut. Argonaut is running an open implementation program, where anybody who’s building an app or an EHR can join for free and go through a series of development steps with us, where they can build out support for SMART on FHIR one step at a time. We’re running this open implementation program and we’ve had a couple of dozen organizations actively participating. That includes many of the big-name electronic health record vendors.

EHR vendors and even providers themselves don’t have much incentive to let patients choose and use whatever apps they want that tie into their legacy systems. How hard will it be to gain traction when the patient is the only obvious advocate?

There’s a lot of moving parts to an ecosystem like that. I talked a little bit about what’s the technology to make the platform work. I talked a little bit about what’s the access control policy. The other big question is, who’s the audience? Who’s using these apps?

We see a very clear motivation on the side of provider organizations to be able to rapidly adopt, and even to build, new applications that serve direct business interests or direct clinical interests. We see a strong internal motivation from healthcare organizations to be able to launch new apps.

For example, we have an app that we deployed at Boston Children’s Hospital that helps take better care of children with high blood pressure. It takes data from the EHR and uses them to compute blood pressure percentiles, which are normalized by a child’s age, height, and gender. That’s how you’re supposed to make a diagnosis of high blood pressure in children, by calculating those percentiles.

The EHR has all the data, but it doesn’t do the calculation, so we built an app to do the calculation. There’s a very clear motivation on the part of the clinical organization to be able to deploy an app like that –it runs inside the hospital, runs on top of hospital data, helps take better care of patients. We can think about other kinds of apps, which might be patient-facing applications, where a patient says, "I want to use this new health management tool I found." That represents a paradigm shift for provider organizations.

It’s still an open question how internally motivated these organizations will be to let patients bring these apps to the table, but I’m very encouraged by the recent Meaningful Use Stage 3 final rule, which came out and said that patients should have the right to access their own health data using whichever apps they want.

It’s been said that people didn’t know they needed an iPhone until it came out. What would be the equivalent that would tell patients that they need interoperable health apps?

I don’t think we’ve seen our first killer app, so to speak, in this space yet, but we certainly see a strong interest along the lines of patients who are managing chronic diseases, where they have to see a number of healthcare providers and the system is not tight knit enough today that the healthcare providers from these different organizations really communicate very well. A patient is very motivated to improve that communication, so apps and tools that help them do that are a powerful selling point.

Another area which we’re only just beginning to explore is apps that help you shop around for the right healthcare services, whether it’s deciding on the healthcare insurance that’s the best fit for you given your actual usage patterns or shopping around for a procedure or drug given the insurance that you have. The more data that apps can access, both about you individually and about other patients in the ecosystem who might be like you, the better you’ll be able to make decisions that work for you.

What data sources would you need to provide an estimation of utilization? Would it be claims data plus EHR data?

I think looking at a combination of electronic health record data plus insurance claims is a very good place to start. There are some open kinds of claims data at the population level the government makes available that you can use for a very rough cut, but I think we’ll also see more partnerships being formed with aggregated data being shared that can help compute better decisions.

Geisinger formed XG Health to commercialize their apps that tie into Epic. Is that an early example of the kind of ecosystem that could be created around legacy EHRs that aren’t necessarily done through vendor-specific proprietary technology?

We’re seeing a trend in several places and Geisinger is a great early example of an institutional drive to innovate and to find a broader market based on these innovations. If you invest a lot of institutional time and money building a tool that works inside your own organization, that’s great — you can reap the benefits internally.

But more and more, there’s a desire to be able to share these tools, or sell these tools, outside of an organization. Anything you can do to build apps in a vendor-agnostic way, to build them in a standards-compliant, openly integrated fashion, lowers the cost of integrating this app with more systems downstream, makes it easier to export innovations beyond your own organization.

Vendor of mobile apps haven’t usually done the research to prove that the product improves cost or outcomes. They also often seem to target users who are already health focused. Will app developers need prove the value of what they’ve created?

I think there’s a few ways to measure the value of an application. One is to figure out how people like it and how they perceive that value. Two is to try to measure objectively how the app performs on some metrics that you define.

One of the really exciting things about this health app ecosystem is you can start to use apps as the instruments of research. We see examples of this happening along traditional institutional lines. For example, Duke Medicine has built an app that they’re using as part of a research project to evaluate how well patients know their medication regimen — how well they know which medications they’re supposed to take at which time of day. They’ve built a tool as a SMART on FHIR app that provides a patient with an interface for saying, "Here’s what I take in the morning, at noon, and at night." They’re able to drag and drop pictures of pills from a virtual pill box into these various categories. Then researchers can correlate how well patients perform at this task with other measures of medication adherence and start to figure out whether tweaking the parameters of this task can lead to improved adherence.

Whether you think that’s a great idea or not, the fact is we can use an app to do a measurement and to produce a traditional clinical research result, which you would never be able to do if you had to start from scratch and integrate this thing into the EHR just to fetch the med list. The fact that you can get the med list from the EHR and get all the patient demographics from the EHR out of the box with standards is what makes that kind of research possible.

Then we also see research happening in other new and exciting ways, for example, with mobile applications that collect data explicitly through surveys and implicitly through sensors. There’s a lot of good work happening, for example, on the iOS platform with ResearchKit in that direction today.

Are patients involved enough in the design of what they want, need, and will use instead of letting health systems manage app design?

I think the healthcare industry always struggles to figure out where and how to involve patients. Frankly, there’s a lot of bottom-up work that’s happening today in the patient application space, where companies are starting to build consumer-facing tools that don’t always make sense to the traditional healthcare ecosystem. But as consumers adopt them, we have a better and better idea of what’s really interesting and useful from the patient perspective.

I think it’s very hard for institutions, in a lot of cases, to do the right thing by involving patients. But we’re seeing very good bottom-up innovation that happens from outside of the institutions, and that might be the best indication we have of what really matters.

What do you expect to hope and see in the next five to 10 years in terms of how systems are opened up or interconnected?

Looking out to the longer term, my main hope is to see connectivity become more and more invisible, to have established pipelines where data arrive where they need to, and are available at the point of care, and are available at home without our having to take many explicit steps to make it happen.

What I’d like to see are clinical systems that understand the job that a user’s trying to do. Understand what it means to make a diagnosis or choose a correct treatment, taking into account clinical practice guidelines, the particular clinical situation at hand, taking into account patient preferences, and making it much easier to understand the risks and benefits across the board.

We need readily accessible data, both from the individual patient level and from the clinical knowledge domain. We need all those kinds of data available at the point of decision-making. My hope is that, by standardizing the core of these data access protocols, we can get there in the next five to 10 years.

Do you have any final thoughts?

From the perspective of the SMART Health IT project, we’ve seen an incredible amount of interest and enthusiasm around these APIs that, when we started building them in 2010-2011, the feedback we often got was that it felt like a science fair project and it wasn’t ready for the real world. The interesting thing is that not that much about the technology has changed, but given the overall landscape of EHR adoption and an increasing level of demand from end users for tools that fit their needs better, suddenly this technology has become incredibly mainstream in really short order. It’s been really humbling to be part of that experience.

HIStalk Interviews Joseph Pocreva, MD, Colonel, US Air Force

Joseph Pocreva, MD is an emergency physician at Keesler Medical Center at Keesler Air Force Base, Biloxi, MS. He is a colonel in the United States Air Force. His views and opinions are his alone and do not necessarily reflect the official policies or positions of the Air Force.

Tell me about yourself and your job.

I’m an emergency medicine physician. I’ve been practicing for about 15 years. I am in the Air Force. I have been working in various emergency departments, Special Operations, and different areas of the Air Force.

I have been here at Keesler for approximately five years and have had various roles while I’ve been here, including flight commander, medical director, and a practicing doctor on the floor.

How much of your career is more military than medical?

Sometimes it’s not very easy to answer that question. There are some physicians who feel like they’re more doctors than they are officers. Some feel they’re more officers than doctors. I have felt both ways.

Obviously when I’m on the floor and I’m engaged with patients, I’m a doctor. Yet when I walk away from the floor, I have to interact with other places, not only in the hospital but throughout the Air Force or with engagements with the Army or the Navy. Then my role oftentimes becomes more of an officer in the Air Force. That’s in my current position.

I’ve had other positions where I had no medical role at all. It was all about being in the military and functioning as an officer. It is a switch that gets toggled quite frequently. I’m not sure if I answered the question very well. I wouldn’t be able to give you a 60 percent, 40 percent answer — it all depends on the day and the demand.

You served on a humanitarian mission to Haiti, correct?

I was in Haiti. That was in 2010, just months before I was assigned here. I was the lead medical officer in Haiti when we went into the country to open up the airfield.

Have you had other assignments or deployments to other locations?

Oh, yes. If you’ve spent any time in the military in the last 20 years, you will have deployed.

My initial assignment was at Eglin Air Force Base in Florida. I deployed to Iraq in that timeframe. I was also stationed at Hurlburt Field, which is the Air Force Special Operations base. I did a lot of shorter missions, primarily to the Philippines. That’s where I went to Haiti as well.

I’ve traveled quite a bit doing a lot of diverse things. A lot of forward medicine, dealing out in the field without a lot of hospital support, just “what I can carry on my back” type of medicine.

How have you used that front line experience from Iraq in your ED job?

I was in a forward hospital there. We had a pretty decent sized staff, but we didn’t have a lot of resources. Practicing emergency medicine in today’s world is very lab- and radiology-intense. In those settings, we just don’t have those kinds of resources. You have to rely on your clinical abilities and your ability to make a decision, which is oftentimes paralyzing to the younger clinician who depends a lot on labs and radiology and their consultant staff.

If you don’t have it, you have to make decisions. Your decisions have serious implications, because if you want to transfer somebody in that setting, you have to get an aircraft to come in and take your patient away. If you can take care of them there versus putting them on a very expensive aircraft … You have to make those kinds of decisions. There’s a lot of differences between forward medicine and medicine back home.

What it’s like practicing in an Air Force hospital ED versus a civilian one?

Some very important key differences. We practice socialized medicine. We have a very captive patient population. They all have primary care doctors. They all have access to medications. There’s a social structure which is well defined. All of our active duty people have supervisors who we can call.

It’s a very different world from the outside. I’ve worked on the outside as well. I’ve moonlit for years at many different institutions and things.

There are advantages and disadvantages to both settings, but working inside the military is what socialized medicine is, in a nut shell. Actually, I would go on to say that, as far as I can tell, it is the best example of socialized medicine that we would be able to maintain.

People forget that military medicine isn’t just taking care of active service members, but their entire families as well, so you have pediatrics, oncology, and other services.

Right. The active duty population is only a small portion of who we take care of. The majority are their dependents and then our retirees as well. It’s everything from cradle to grave.

Is military medicine care at least comparable to what is offered in civilian settings?

It is somewhere in the middle. I’ve worked in plenty of hospitals that had nowhere near the capability that we have. Then you go to some of the major medical centers which have comprehensive care … When we have patients that are beyond our capability, then we will refer them to, in our case, the University of South Alabama or the Jackson Medical Center up in Jackson, Mississippi or over to Ochsner in New Orleans. We rely pretty heavily on them.

As far as the bread and butter basics of medicine, into surgery, into your medical specialties, and what have you, what we have is quite comprehensive.

What technologies and IT systems do you use in your practice?

We have CHCS, which is our basic underlying database., It’s been in place since the late 1980s and we’re still using it to today. That is where we record all of our labs and radiology and that’s where we do our prescribing from. As old as it is, it’s solid as a rock. It never goes down, ever. Everything else can go down, but CHCS still manages to keep plugging along.

On top of that, we have a graphical interface software solution called AHLTA. When it works, it works all right. [laughs] It is a program which is designed to interface with CHCS and pull data from it, as far as all of CHCS capability. But it’s also for record-keeping and and electronic medical records. We use it primarily just as an interface to get to the CHCS data.

In our emergency department, for our recordkeeping, we use T-System, which is hands down much better when it comes to data entry than AHLTA is. Much, much, better.

Those systems may be replaced in the DHMSM project. Are you looking forward to that or concerned by it?

I don’t really know a great deal about it. I understand that Cerner won the contract to provide the next generation. There’s generally the understanding that it’s going to be coming sometime in the future. After that, I think I know enough in my career that I don’t get too excited about dates of when it’s going to come, so I don’t know when we’re going to actually see that.

I would be very surprised if it has an interface which is more user friendly than T-System. Hopefully we can find a way to integrate T-System into it. But beyond that, that’s just all conjecture, and I don’t know — I’m not a part of that whole process.

I’ve read that 60 percent or more of care delivered to military members happens outside of military facilities. How do you communicate with external providers?

That 60 percent probably reflects most of the places not around the larger institution. Around here, we probably deliver considerably more than that in our facility. But so many of the smaller bases have been reduced to clinics. A lot of that referral work and surgical procedures and things are going to be done on the civilian side, so I think we do a great deal more of it here.

However, when we do refer people out to the community, they are not on our informatics databases. We have to rely on them doing a consultation and sending the reports back to us. Then our information people enter that data back into our system. It’s a rather slow and cumbersome process.

Do you have a lot of overlap in the information that you either need from or provide to the VA?

No. We see a lot of VA patients. We have a pretty robust interventional cardiology practice here, so virtually all of their cardiac caths come here. We have a lot of vascular surgery. A lot of the VA patients come here, but we don’t use their systems, nor do they use ours. If we want that data, we’ve got to go and request it old-school style.

How long do you plan to stay in the military?

I have been in the military for 23 years right now. I will be getting out next year. I’ve already put in my paperwork to retire. I should be retiring somewhere around the first of August in 2016. I will likely be joining a local practice here in the area.

What will you miss in not being part of the military?

The people, without a doubt. My grandfather was career Navy. My father was career Air Force. I’ve been on the Air Force welfare system since I was born. I don’t know anything different.

Not only taking care of this population, which is something that is very important to me, but working alongside a lot of people who really care about being here and doing the mission and being part of something much bigger than themselves is one of those intangibles that is very difficult, if not impossible, to find anywhere else.

It will be a sad transition for me, I’m sure. Although the local hospitals around here are wonderful by any marker, it’s going to be difficult to walk away from an institution like this.

People with no military connections admire the patriotism, discipline, and sacrifice involved. Is it equally impressive from the inside?

Oh, yes. Yes. You see people with talent and abilities and what have you. You look at them and you think, "Man, you could be making a million dollars on the outside, and yet you’re in here doing this job.” I really appreciate it.

That really comes through and shines when we’re deployed. When you’re out there and you’ve been away from your family for a couple of months and people are still putting their shoulders to the grindstone and just working hard.

Sometimes the situation and the environment we’re in is less than ideal. We’ve yet to go and occupy a really great place. [laughs] We tend to deploy to less-than-ideal locations. It’s very impressive when you see people step up and do the amazing work that they do. It’s an honor to be a part of that.

HIStalk Interviews Mike Nelson, CIO, Universal Health Services

Michael Nelson is CIO of Universal Health Services, a publicly traded, Fortune 500 hospital management company in King of Prussia, PA that is also the parent company of Crossings Healthcare Solutions, which offers advanced clinical decision support software for Cerner Millennium users.

Tell me about yourself and the company.

I’ve been with UHS for eight and a half years as a chief information officer. In those eight years, the company has doubled in size from $4 billion to $8 billion in revenue. We’re a healthcare provider-based organization with roughly 25 acute care hospitals and $4 billion in revenue for that division and 215 behavioral health facilities with roughly $4 billion in revenue for that organization.

UHS is the parent company of Crossings Healthcare Solutions. Crossings is where we’ve had the most clinical innovations that we sell to the market, but that functionality was all created and embedded for UHS use. We’re not trying to make a material profit with our Crossings subsidiary, but rather subsidize having a lot of clinicians involved in IT. That’s the real purpose.

You’ve worked for both non-profit health systems and now a publicly traded, for-profit one. How are those settings different?

Prior to working at UHS, I worked for the Carolinas Healthcare System in Charlotte, North Carolina, a well-run, large integrated healthcare delivery system of hospitals, physician practices, etc. They are a well-run not for profit. As I transitioned into the for-profit sector, I had curiosity as to what the differences may be.

The founder of UHS is still here 35 years later, Mr. Alan Miller. I think UHS is a little different from your standard for-profit company in that it has been established and it operates for the long haul. We insource and operate the majority of our IT. We pay Cerner to host our EMR platform, but we run our own help desk. We run our own help desk for the Cerner platform. The PC tech team is ours and not outsourced. We look to operate efficiently and effectively, providing good services from an IT perspective.

Even though we’re for-profit and publicly traded, we are operated for the long haul. In my eight years, I was never asked to decrease staffing due to a challenging financial market. If you think back to 2008 and 2009 when times were tough, we did not reduce head count because we’re very careful in what we add. We want to operate efficiently and continue to serve the customers and the physicians well.

I think UHS is a little different in that regard in the for-profit world. I’ve found that our goals are substantially the same — quality, patient safety, and have IT deliver effective services to the customers. A lot of those themes are exactly the same in the for-profit world, even though I would say there’s an incremental focus on expense management.

For-profit healthcare IT technology deployments seem to have been selective, with less investment in clinical and patient-facing systems. Did you find that to be the case at UHS?

When I got to UHS, they had a best-of-breed focus, as did many organizations  back in the early 2000s. We had an opportunity to reconsider that approach.

As I joined the company, the revenue cycle was stable and effective. There had been a major investment in what used to be the Siemens Invision platform, which is now owned by Cerner. The corporation needed an improved clinical IT, so we went down and determined our strategy was going to be a more innovative approach.

As we started the Cerner EMR implementation, I advocated for – and the president of the company, Mark Miller, supported — adding a chief medical information officer. Until we started our Cerner deployment, we didn’t have that. We added that one physician. Then that physician was so effective for us that we added three other full-time physicians in IT.

As far as I know, we’re the only for-profit that has four physicians full-time embedded in IT that sit across from my informaticists and my programmers on the same floor in our building. Our cycle times to make modifications, customizations, and enhancements is reduced because of the close physical proximity and the alignment with IT.

I think your characterization of for-profits is generally accurate. Between the work that Tenet and Community and we at UHS have done in the last four or five years across those organizations, there has been a huge focus on clinicals. We added clinicians into IT and I think that’s the secret sauce to having enhancements that we’re able to sell to other people.

You mentioned that you have a lot of behavioral facilities. Is the technology deployment different there as it usually is outside of the hospital setting?

We have different IT in the two divisions. We run different registration and clinicals in behavioral health as opposed to our acute.

In the behavioral health division, we have been piloting a couple of different EMRs that are better adapted to that environment. They have some documentation requirements and clinical processes that are materially different than acute care. A standard acute care EMR has not worked well in the behavioral health division. Lately, we found a vendor that’s a pharmacy IT vendor that has CPOE, etc. and leveraging that specialty system into our behavioral health has produced the best result so far.

They’re not running ORs, typically. They don’t have a lab. They’re not running radiology. Finding a good niche pharmacy system that has a CPOE component that allows the behavioral health to be effective with patient medication management — that’s really been the right piece for them. But we do have EMRs in select facilities. Then our acute care division is very standard with the rest of the acute industry.

There is separation differentiation at some of our large acutes. We have behavioral health pavilions, large inpatient units. At those locations, they use Cerner. We’ve worked to enhance Cerner so that it can meet the majority of their needs. We’ll continue to do it as we go forward.

What can you do with Cerner’s MPages and Advisors?

We can aggregate data that are on multiple screens within the system into one unified view. Instead of a physician having to go through seven clicks to renew a medication order that’s about to expire, we can have an MPage that displays all the med orders or any other orders, such as restraints, that are going to expire. Basically in one click to two clicks, they can renew all those orders when typically they would have to navigate to the orders page, review all the orders, determine which ones might expire, select those individual ones, and approve them.

Our goal using the Cerner tools has been to reduce the clicks for the physician and present information that they can take immediate action on and solve the conundrum of "Yes, the EMR has what needs to be done, but it’s not easy to get to it, it’s not easy to take that action, and IT, you guys aren’t providing me any value with the out-of-the-box EMR."

Do inpatient EHR vendors offer enough tools and technologies to allow users or third parties to extend or modify their basic functionality?

I can speak from my experience with the Cerner EMR, having implemented that at the Carolinas and at UHS. The MPages functionality, the Cerner Command Language CCL Programming tool set, has allowed us to extend the functionality of Cerner and address workflow issues that we see. That’s been good technology that when properly leveraged, adds real value.

Other vendors might not have been flexible enough early, but you’ve seen Epic adapt to that. They’ve rolled out equivalent functionality from what I understand, but I haven’t used it directly. How much or little Meditech does, I don’t know.

A lot of vendors that are smart realized that healthcare is not one size fits all. You don’t want to just let them have configuration choices — you want to let them enhance the tool. The direction is more positive as opposed to less. I’m pleased with Cerner. We’ve been able to get real value from that.

Are you hungry for additional capabilities to the point that you’re asking Cerner for more openness or APIs? Do they see that as competitive with what they want to offer the market in general?

We are actively working with them on some technical tools that are going to provide better alerting and information from a technology perspective.

I worry about end-to-end response time. Our end users in the hospitals are on a PC. They’re going through a Citrix session. They’re connecting across our wide area network to the Cerner data center. There’s an application set of functionality and  there’s a database server. I care about that end-to-end response time. Cerner has got great tools to manage the database and tell us what the database response is, but they can’t tell us Citrix session response times front to end in our facilities. We’re working on trying to get them to allow us to do some different things and installing tool sets in their managed services environment.

We’re pushing and advocating for the things that we need from an IT service delivery perspective and I think they’ll react to that. It will take a while. There’s still continued tools that we need, but it’s a step at a time. It’s a journey with the EMR stuff. Nothing is ever done overnight. if you think about client-server, that was the rage, but eventually people wanted to push everything to the cloud. You go through technical changes, but what you want is effective IT delivery for your end users.

Was it different to have to take a vendor mindset when developing something new that could be used, hopefully in shrink-wrapped fashion, by another health system?

Absolutely. We added several technical staff members to help package up code sets so that it would be deployable to other organizations. Cerner’s EMR and other vendor EMRs have configuration choices. Based on those configuration choices, our enhancements may work more straightforward –out of the box, if you will — or we may have to modify those enhancements to meet the configuration choices that a customer made.

We invested resources and time to package up the enhancements so that they were more readily usable. We worked to add some user admin tool sets so that they could modify some functionality without having it have to be hard coded and programmed into those solutions.

Absolutely, you cannot just take an enhancement we’ve made and plug and play it somewhere else. You need to think through that commercialization and how do you package that up and get it ready with release notes, etc. We went into with a mindset that we would have to, for our Crossings subsidiary, invest in commercializing the software, which meant packaging it up, making it ready for deployment, and usable. We’ve worked hard to make that effective at our first customers.

Vendors are announcing customer partnerships, like the Cerner-Intermountain one, where they’ll work together to develop intellectual property that will be added to the vendor’s base product. Is that a growing practice? How will it affect the industry?

Through the years, you’ve seen an increase in that. Cerner previously had a relationship, I believe, with the Chicago Institute of Rehabilitation. They had a rehab-specific module that Cerner customers could purchase. Other vendors have had different types of announcements with third-party organizations. I think that will continue in a limited fashion, where that third party can help the vendor create functionality that would have otherwise taken the vendor too long or they might not have gotten to and lost a market opportunity.

Cerner has worked with Advocate on the population health side. I think that’s helped  Cerner move more rapidly than perhaps they could have on their own. I think it’s a smart move from the vendors. They’ve got to pick the right organization that has similar business needs to other possible customers to create products that offer real viability in the market. It makes sense on a limited basis where they can control and manage the scope. It keeps them ahead of what customers are demanding.

I think it’s in my personal best interest that Cerner has as many products as I might want. It’s my personal opinion. Some of it will apply to us, others of it may not, but I think you’ve definitely seen a continued trend to do that in a focused manner.

It’s disillusioning to a clinician who moves to the vendor side to realize that what’s holding innovative functionality back isn’t always a shortage of good ideas, but rather navigating through convoluted internal development, testing, and release processes. Have technologies changed so that a good idea be turned into a software enhancement quickly and reliably?

Technology has given us capabilities to decrease the time for that development cycle. But there is still idea generation and requirements definition and modification that still takes time. That human side of coming up with a better idea, working through how it could function, going from a verbal design discussion to a technical set of specifications that you can program for. I think there’s still real time in that. 

Once you get to the programming side of the house, there are some tool sets, testing tools, testing environments, and repeatable test data. That technology has shrunk down that total development time, but I don’t think it can necessarily eat into that timeframe that’s on a front end, to come with the idea and create something that’s viable that then you can handle the technical life cycle on. I think we’ve made some progress.

Within our organization, there are more good ideas than we have people. Most IT shops probably have that problem. You prioritize them and work through them in as smart a manner as you can.

What will be most important for you to accomplish for UHS in the next five years?

For IT, I want us to be flexible and responsive to the organization, which everybody certainly wants. But where I see our business and clinical priorities are increasing are focused on population health. We as an organization purchased an insurance plan. We are offering Medicare Advantage plans. We are working to provide narrow networks. 

As we in the IT realm move from having an EMR deployed that we believe is relatively effective and physicians inside the four walls of our hospital using that relatively well, we need to then look outside of those four walls to the post-acute world. We need to look to managing that population health, providing the quality, and having the data and information to do all those things.

I don’t believe that’s necessarily materially different than other large providers. Working to align IT and making sure that we can effectively support good decision-making, quality improvement, and quality patient care delivery. Those are probably the most important things at the top of our list while continuing to be effective inside the four walls of the hospital.

Do you have any final thoughts?

I’ve enjoyed reading HIStalk for a long time. I think you bring a nice breadth of practical and honest information-sharing across the healthcare IT space. I appreciate what you’ve done. We hire kids out of college. We work to train them and grow them and try to create their interest in healthcare IT and you are a great source of information for that. I know a lot of others read what you  have. You know I’m a long-term reader and I appreciate what you’ve done. You’ve made it very practical for people and cut through the BS, which is great.

HIStalk Interviews Bill Anderson, CEO, Medhost

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

Tell me about yourself and the company.

I’ve been involved with Medhost since 2007. I was originally an investor and a board member. We’re about a $200 million revenue company with both enterprise products and population health and consumerism products.

What has been the market reception following the company’s name change a little over a year ago?

We’ve acquired two different companies to go with what was originally Healthcare Management Systems. One being the original Medhost EDIS company and the second one being the Acuitec perioperative system, which was the old Vanderbilt system. Simplifying our inpatient system has been well received by the marketplace. The consolidated branding makes the company much more understandable to our customers and other constituencies.

What are the steps involved in kicking off talks about an acquisition?

We believe that we’re as much a distribution company as a technology company. The number one criterion for either buying a company or spending money internally is to try to understand what our customers’ needs are. Ideally we can anticipate those needs before they actually understand they need them.

In those two cases, for instance, these were very critical profitability centers for facilities. We believed that offering not just good enterprise departmental solutions, but best-of-breed leading solutions, was something that was going to be important to our customers. The ED and the operating room are two places they have to make money to make money. It’s really very customer driven.

You told me when we spoke last time that your main acute care enterprise competitors were McKesson Paragon and Meditech. What has changed since?

They’re both still substantial competitors. We are seeing some more competition from Cerner’s Works product, but it is in many cases more difficult to come down-market than it is to go up-market because of the complexity of the product. But largely the competition is very similar to what it was the last time we talked.

The inpatient market differentiators are usually facility size and the complexity of the app as well as the cost of buying and running these applications. How has the dynamic changed as Cerner and Epic push into smaller hospitals and large hospitals are buying their smaller competitors?

I may give you more of an answer here than you’d like. One of the things we are very concerned about is the profitability of hospitals in the middle market. Let’s say that is 50 beds to 150 beds. What has happened today is that regulations have increased the fixed costs to those facilities by mandating a lot of different systems — mostly in the IT area — and other activities. At the same time, the average revenue per customer is dropping. You see a continuous stream of news articles about the crisis in rural hospitals, particularly.

As a result, I’ve seen analysts say things like, we’re going to take 40 percent of the total facilities out of the system or 30 percent of the beds out of the system in order to get facilities to a reasonable profitability. We look at this and we say, the total cost of ownership is something that today is not only a good business practice to be conscious of, but it’s absolutely essential to the survival of these hospitals.

We’ve tried to have — and I think hospitals in general are looking for this — what I would call segment-appropriate features. Physicians, for instance, would like to have all the features you can possibly get, but the more complex the system, the more cost is added to it. We believe that total cost of ownership is a very key thing. We’ve tried to manage our systems to be able to help our customers do that.

One of the things that I always point to is that back in the mid-1980s — I used to be in the banking software business — there were about 18,000 banks in the United States. Today there are about one-third that many. If you look at the reasons that happened — increased regulations, access to capital, all those types of things — the same types of things are happening in the inpatient facility business. We’re very conscious of trying to help our facilities control costs because it’s in our self-interest to have them survive.

Banks invested heavily in technology to keep customers from tying up an expensive live person, such that most people now hardly ever go into the physical bank. Does healthcare have the incentives to deploy that kind of automation?

I’m not sure that you can have the same level of automation in healthcare that you have in banking with self-service. But one of the reasons we’ve heavily invested in our YourCareUniverse product suite is to help facilities manage two different digital communities, which we think are important to them — a digital community of consumers and then a digital community of providers and patients who are actually in the healthcare arena.

We think that is the analogy to the banking industry. Our facilities are going to have to learn how to manage these digital communities. It’s not going to be so much of a community-based facility as an area-based facility in the past. For instance, we have a little hospital out in Texas that covers eight counties in Texas. There’s a lot of real estate in eight counties in Texas. They need the ability to not only interact with the community, but with their patients.

The second thing we’re starting to see and having our customers tell us — particularly our big customers – is that consumerism is really starting to bite. Similar to the banking industry, you will see that things that were previously done inpatient may be moved to outpatient, whether an ambulatory surgery center or a physician’s office or some other venue outside the four walls of the hospital. Things that may have been done in a physician’s office are going to be moved out to things like MinuteClinics and urgent care offices and maybe even to self-service with the consumer, with the patient. I see very clear parallels to the banking industry. 

Healthcare providers in general are saying, we’re going to be ready for this shift, because while you see it starting to happen, it’s going to take some time. The people who are preparing for that shift today, we think, are going to be the long-term winners as the market consolidates.

Are your clients confused about who their competitors and potential partners are?

It’s very challenging environment. Because of things like access to capital and the systems that are required, you see — not only in the large integrated systems, but in geographic areas — hospitals partnering up with larger facilities. You mentioned Epic moving into the smaller facilities. This is an example of how large geographic areas are handled by a large facility integrating in smaller facilities. That’s what’s happening a lot.

I think it is going to continue to be a challenge for healthcare providers to understand what the best partnership strategy will be for them. Some of these customers of ours are going to end up being purchased by other customers. Some of them are going to affiliate with ACOs or large facilities. Some of them may be in an area where they can go it alone. I don’t think there will be a single strategy because there are so many different factors involved about what the market is, the financial strength of the entity, and what the competition looks like.

We have significant EHR adoption in the inpatient and ambulatory markets. Are post-acute care, home care, and behavioral the next frontiers in trying to move patient information from paper to electronic so that it can be shared?

Yes. We’ve got a number of really large customers and they have many different types of facilities as well as clinicians and ambulatory systems. One of our frustrations — even though we’ve built tools to help tie all those together – has been getting cooperation from other vendors. No one wants to be disintermediated away from their customer.

What is clearly the right answer for the facility and the right answer for the patient — which is to provide a totally integrated system that exchanges data and allows you to make orders and do all sorts of other things — is really very difficult to execute because there’s not alignment of economic interest there.

Companies ranging from tiny app developers to big enterprise companies like Salesforce are trying to figure out patient engagement. What technologies are needed and what will determine whether a vendor is successful?

We think that there will be a market evolution similar to what happened in the inpatient business. Many facilities, particularly big facilities, used a best-of-breed strategy and effectively brought components of a total system based upon individual features of that system. I think in the long run, customers are going to say — just as they are starting to say in the inpatient market, in the enterprise market — that it’s really difficult to manage a system that is cobbled together from a number of different vendors. The clear trend is a single provider for your inpatient systems.

Our approach — and what we think will be most likely to win in the long term — is that we have focused on not just having good individual components like analytics or a CRM system, but that we have a totally integrated system. That’s what the customer is going to ultimately demand.

For instance, when we did our patient portal, instead of having a tethered portal to an EHR, we built a private HIE. We’ve got both an ambulatory and an inpatient-certified Meaningful Use portal on top of that. On top of that, we have both an analytics system and a CRM system that allows you to not only track patients and all their data, but to aggregate data within a community.

Where I believe this is going to become particularly important is if in fact the Meaningful Use guidelines for view, download, transmit actually go to 25 percent. Our understanding of the regulations is that in a community, if you had information as a clinician in the hospital system and you had a single portal for both the ambulatory and inpatient providers in that community, you could effectively pool traffic. There are going to be instances where not only the market, but regulation is going to require that you have this totally integrated system, because otherwise you’re never going to get to a 25 percent view, download, and transmit standard, for instance.

What possibly unusual assumptions are you using for the company’s next five years?

Our assumptions are threefold. In the inpatient market, we believe that there are probably at least 1,000 facilities in our relevant market space — the short-term, acute-care market — that have not made durable enterprise product selections. While it is a mature market, at some point in time, as customers and the market get over the Meaningful Use trauma, they’re going to start replacing systems that are not going to meet their long-term needs or they will have a question about whether that vendor is going to be there for them five to 10 years from now. One of our assumptions is that consolidation in the vendor market — just like consolidation in the provider market — will happen sooner rather than later.

The second assumption we’ve made is that while people talk about population health, and while we have a complete population health solution, we think the most important thing is going to be addressing the consumerism needs. Specifically as more and more healthcare moves out of the inpatient setting, in order to survive as an inpatient provider, market share is going to become increasingly important. Therefore, the number one skill set that our customers don’t have today that they need to build is marketing.

We’ve started to provide tools to help them to market to the community. That includes our YourCareEverywhere content site, which is a co-branded content site. If you’ve looked at most hospital Web sites, it’s about the hospital, not about the consumer. We’re big believers in that if you’re going to engage with a consumer, you have to provide them continuous value — not just value when they’re a patient — as well as an analytical solution and a CRM solution that allows you to market to the community based on needs.

We think our focus on the consumerism side of the equation is much different than most of our competitors in the middle market.

Do you have any final thoughts?

Today I believe there is a determination being made between the facilities that are going to be survivors in consolidation and those who are not going to survive as standalone entities or even as entities at all. In many cases, unfortunately, the management of the facility does not really understand that that’s happening today. If you’re too late to address these specific issues, such as consumerism and partnering and things of that nature, it may be  too late by the time you are willing to address the issues.

HIStalk Interviews John Kenagy, PhD, SVP/CIO/CISO, Legacy Health

John Kenagy, PhD is SVP/CIO and chief information security officer of Legacy Health of Portland, OR.

Tell me about yourself and Legacy Health.

Legacy Health is headquartered in Portland, Oregon. We’re a health system that operates in the southwest Washington / Portland area with six hospitals — two urban, a children’s hospital, three suburban hospitals, and a number of clinics. It’s a typical community-based health system with employed physicians and clinics, moving towards population health and more risk. A very traditional health system founded in 1875.

I have been the CIO here for about three and a half years. I’ve been a CIO for 26 years and have had the distinct honor to have worked in interesting organizations that were each very different. First in the VA system — I worked there for 13 years with my final job as a regional CIO, Then Oregon Health & Science University, the academic medical center here in Oregon. Then Providence Health & Services, a Catholic system throughout the west. Now Legacy.

What discussions are you and your peers having about how the organization should look in five or 10 years and IT changes that will be needed to support those changes?

Two themes are recurring and they’re very interrelated. One is the whole area of population health and risk. Value-based purchasing is risk, taking the entire premium and accountability for lives. That transition from paying for providing healthcare to maintaining health and what that implication is organizationally and of course from a technology perspective. The other one is around insurance. We’ve been a traditional healthcare provider for many, many years. Do we — through either partnership or de novo creation — get into the insurance business? 

Let me start with the first one, because I think it’s challenging and fascinating. I think all my peers are working on the same kind of issues, which is, as we move from patient care to population health, it is forcing us to look beyond the four walls. Whether that’s accountable care organizations, bundled payments, or again risk for care not only delivered in your organization, you want to do it the best value — the optimal quality at the lowest cost.

What happens when that patient is on vacation and goes to an ED? That cost is now attributed to your bundled payment, readmissions, and working outside of just the four walls. If you are a traditional organization like Kaiser or the VA, which has all that care within its organization, that’s one thing. You can control the IT, systems and access. For an organization like ours, which is very much a community-based hospital system, we employ 500 doctors, but our medical staff is 2,000. Those other 1,500 are not on our EMR. They’re very independent. They value their independence and worry about when the hospital tries to get more into that.

In the future, with population health and new payment mechanisms that focus on the overall quality and experience of the patients, it’s really a good thing. We’ve been working many years on integrating all of our data into a single system. We are an Epic shop and love the fact that we have an integrated information system, but now with population health, we are consciously moving away from a 20-year ride toward integration into a single database only to say, "That’s great for our hospital, but now we need to play well with every other EMR and now claims data and insurance information."

The complexity of how to do that is extremely challenging. We’re working through that right now, as I think many vendors are, and of course the EHR vendors as well.

Some publications and Epic detractors claim there’s a backlash against Epic after all these years. Is that the case? What is Epic doing right and wrong?

I see that a lot. The paparazzi follow the popular stars. Bad press comes to successful people. It’s our sick culture of wanting to kick the person in the top primary position. I think that’s what’s happening with Epic right now.

I am very pleased that we have Epic as our partner here at Legacy. I think that makes our healthcare better because of the integrated system across inpatient ED and outpatient, not to mention revenue cycle and all the other things. It’s an amazing organization that is very dedicated at its core to a patient care, but also to the success of its partners. I value that greatly.

I wouldn’t say this is what they’re not doing well, but they are burdened by the fact that they are a fully integrated system and have everything from hospice and home health to very acute ICU. You have niche players in the population health space that are coming in a little bit with snake oil and saying how fabulous they are and it’s very easy.

These other vendors, these competitors — particularly in the population health space — are 100 percent dedicating all their energy, all their R&D, all their engineers on that niche product. That’s hard for Epic because they need to do that and other innovations while also making sure that we successfully meet all the Meaningful Use requirements and the transition to ICD-10. I wouldn’t say that that’s something that Epic is not doing right. 

When you have an integrated system — CIOs deal with this all the time — we’re having to re-market that value of integration when in a niche clinical practice, operation, or this case pop health, our operational colleagues come with, "Here’s a vendor that’s promising to make it easy and doable." Everyone says they interface with Epic, but that makes it hard.

Which systems do you think you’ll need to buy from somebody other than Epic?

The big one, obviously, is blood bank. The easiest answer to that are the areas where Epic doesn’t have a product. If you’re a Meditech hospital, you can run payroll, materials management, and general ledger on your platform. Epic doesn’t do the administrative systems. They don’t want FDA regulation — not to speak for them — so they don’t have a blood bank system.

Obviously the items that are closer to clinical care and quasi-biomedical and quasi-EHR. One I’m thinking of is Provation for gastroenterology. We have a number of specialty clinical systems that attach into that system. Fetal monitoring, for instance.

The one that is challenging is business intelligence reporting and population health, where so much of the data resides in Epic but there’s also an incredible amount of data that is community EHRs and insurance information, payer information, and claims data.

We’re actually running two horses in the race. One is Epic and one is a different partner. Seeing where our long term is. I believe we’re in such the early infancy of that BI population health analytics world that I don’t think there’s a clear winner yet. We are exploring both Epic and partnership with Evolent in parallel.

Are genomics and personalized medicine important to your clinicians?

I don’t hear it. I love the way you phrase that question. Is it on our radar screen, or is it something that I’m being asked by our clinical folks? Not yet.

As a CIO, you’re always worried that there will be a sleeping giant, and then at the eleventh hour, we’ll get a knock on the door and they’ll want it in two and a half weeks. We’re keeping our ear to the ground, particularly genomics and how it would relate to pharmacy prescriptions and treatment planning. I think it’s probably end of the decade at the earliest. That’s kind of an off-the-cuff answer, but I think it’s going to be on our radar screen, but it’s not immediate.

If I’m a health IT vendor or consultant, how will my business change as big health systems get even bigger and swallow up what would have been their smaller competitors or different types of providers?

I’ve heard this era called the post-EHR era, which is funny, because it’s more like the post-EHR sales era. We’ll always have our EHR. 

The challenge for us as providers and what we seek vendors and consultants to help us with is a combination of merger and acquisition. The bottom line of this is all the data needs to come together at the right point for making decisions, whether that’s a broader decision around going into a business or what do I prescribe to this patient right in front of me. As I said, our industry’s had this 20-year march towards moving from best-of-breed and integrating into holistic systems that see the patients together, a Cerner or Epic or Allscripts where you have a fully integrated record.

We are at Legacy at HIMSS 7 across all of our hospitals, so it’s a really successful deployment of Epic everywhere. Now we’re saying, we’re going to merge with a smaller hospital that has Meditech. We need to work very collaboratively within our community, within the larger ecosystem. Inherently that is 45 deployments of about 15 different EMRs and how to do that well so that the data that are relevant to making a clinical or operational decision is readily available.

That challenge, while we’ve been focused on integrating to a single system … the funnel has become narrow, and as soon as we’re at that narrow point, now it’s open wide. Get data from, as I said earlier, claims, other EMRs, and even people who are not yet automated. That’s a big challenge. We’re all forging this new ocean independently and a little bit alone. It’s interesting to be Christopher Columbus in this era.

What kind of services or service venues will be developed in recognizing that a hospital’s future isn’t just keeping beds filled?

That’s a great issue. It is something that’s on the top of mind of our leadership team. Moving even the paradigm from beds and hospitals being a profit center to being a cost center.

We’ll always need beds. America is aging. Acuity rises. What we’re doing is taking low-cost, low-acuity out of the hospital and even outside of the ambulatory to the home. What you’re left with is beds that are incredibly required and incredibly acute. You become an inpatient because you need nursing care, not for almost any other reason. Very high-tech stuff that happens in the hospital, but also around-the-clock surveillance by nurses. That challenges us to be able to incorporate data from the home and ambulatory and get that to clinicians so that people are being able to look at change in status regardless of the venue.

Once you’re discharged after an MI, are you gaining weight? Are you retaining water? Is there an issue with taking your medications? Being able to intervene in a trajectory earlier on rather than waiting for it to become acute and come back to the ED and have a readmission. From a data perspective, it really is a challenge to bring all that information and analyze it with machine code to inform and give the right care manager information at his or her fingertips.

Will costs eventually go down? Health system budgets always seem to grow no matter what reimbursement pea is put under what shell.

The cost of healthcare is interestingly a big topic with our board. Our management has been working on it all along, but it’s raised the attention to the board as the cost of the healthcare in America and what percentage of a company’s employee costs are going into the healthcare costs.

Our board members are community leaders. Some are physicians, but a number of them run their businesses. They’re great leaders in the Portland and southwest Washington communities. “It’s costing me more, so what are you doing, Legacy, to help bend this cost curve?" When the board has a focus on something, we in management pay attention as well.

I think that there will be improvements in cost. Not in the sense of quality, so that’s what the balancing act is. Value is a mathematical equation with outcomes and satisfaction on the top and cost on the bottom. You reduce value by increasing cost because the denominator goes up or you decrease value if outcomes and patient experience go down as you put too much attention to cost.

We’re working with a company called Strata Decision. That’s our financial management system. We’re one of the pioneer adopters of what they’re calling continuous cost improvement. It is a way to bring clinical quality and cost data together and inform managers of needless variation and where costs are going up. I’m very excited about it. I think a year from now, we’ll have rich information in the hands of managers, the OR, the orthopedic product line, and the cardiology product line that will inform them of variations in quality, variations in cost, and focus their attention on doing things that reduce needless variation.

Measuring patient satisfaction gives patients a voice, but there’s the question of whether they are qualified to evaluate anything beyond the hotel part of their hospital stay. Do you talk a lot about how to balance patient satisfaction versus the quality metrics that they probably wouldn’t even comprehend?

We do a lot. The interesting driver of that is transparency. Patients trusted their doctor. They certainly didn’t trust their insurance company and they barely trusted the hospital, but they certainly trusted their physician. When the physician said, "You need to become hospitalized and I’m referring you to Legacy because I value them," patients assume a level of quality because they don’t have the data. They don’t understand what quality looks like.

As information becomes more transparent about outcome quality, whether that’s Healthgrades or HealthCompare, we’re doing a lot to engage patients. We’re starting to deploy GetWellNetwork at all of our hospitals to get real-time patient feedback from inpatients. Rate your pain. How are we doing in terms of informing you of what’s going on? It’s not just TV and infotainment. It really is a way to get patient engagement real time.

It is a national commitment, particularly in Medicare, to do post-hospitalization surveys. You get that survey and it runs through their process, so you know six weeks later how the thing was. That’s driving the car looking only in the rear-view mirror. Being information driven. Being able to solicit information and feedback from the patients during their stay about how informed you feel, how satisfied are you, is there pain and other experience during the inpatient stay. Being able to intervene on that real time is a big driver for us.

How does a health system avoid becoming the next front-page breach victim?

You can’t, which is a bleak answer to that. I’m beginning to hear in the CISO industry in healthcare the need to change the paradigm from villain to victim.

The one that I am very concerned about is that the breaches that are happening now are very concerted, usually foreign, usually well financed. It’s not just the simple hacker that’s trying to get something or the “I Love You” virus that someone gets their jollies putting that into the email system and that propagates around the whole Internet around the world. We’ve got a lot of things that solve that. It’s the persistent phishing, very pernicious attacks, Anthem and the very big ones.

I don’t know how I alone at Legacy with my information security team – a great team of five people and our 300 people in IT – can be our own shield against the People’s Republic of China. I just don’t know how that is the expectation. We’re fairly sophisticated in terms of our information security portfolio compared to a smaller hospital or a physician’s office, but if the commercialization of medical record numbers becomes 20 times the value of a credit card number, how am I supposed to defend against literally a foreign invasion done through electronic mechanisms? I think there needs to be a lot more federal attention to that.

If we have a violation like that, because of HIPAA, we become a villain. Turning a blind eye and basically saying, "There’s no defense and I can’t help myself" is an abrogation of your responsibility. But putting in the normal standard things and even advanced systems and surveillance and protections, you still get violated by persistent attack, a foreign-generated persistent attack. We have started changing our language from “if it happens” to “when it happens.”

Should there be a different level of concern or public announcement if information was actually used versus just exposed?

Right. Both our laws and the way we deal with it need to step up to where we are in terms of the real risk. All of our laptops are encrypted. Flash drives are encrypted. All of our actually desktops, so if you break a window and steal a desktop, data aren’t stored locally on drives any more and all that sort of thing. That kind of due diligence.

Like you said, it is the persistent attack. That’s a different level of breach. This whole cybersecurity thing has been a boon to the identity theft industry, because the first thing you do when you’ve lost medical records is pay for everybody having identity theft protection. I personally probably have five offers of identity theft protection at probably $2.30 a person from five different companies, including my insurer, Target, and Home Depot. There should be a minimum on that for the whole country rather than every organization paying into that sort of thing.

What are the biggest threats and opportunities in healthcare IT as you see it from the CIO’s chair?

The biggest opportunity is bringing in additional data. Building off a platform, for us as a provider system with an integrated electronic health record and a fabulous partnership with our vendor, to springboard that. To just bring more information that improves the care of patients, inclusive of claims data and data from other EMRs where the patient is seen. Being able to coordinate care better across a large ecosystem that is very independent.

It’s not a single national health system. We have a multi-faceted delivery of healthcare. Being able to use information and data to enhance that coordination of care in a way that masks the organizational complexity of the healthcare industry. That is exciting to me because I think that that will improve care, reduce cost, and deliver on the Triple Aim that we’ve all been striving for and that is so data dependent. That’s both the threat and the opportunity. The opportunity is that we know what we want to achieve, and then the complexity of having to get to it.

Another threat that I see on the horizon between now and the end of the decade is, for me at Legacy, retirement of very good IT professionals who have more than two decades of experience with our organization. The complexity of hiring people, finding talent, finding talent in unique places like nurses who come in to the organization to become IT analysts. How to marry the phenomenal skills of clinical practice and information technology.

That whole theme is staffing and resources because technology is the simple part. It’s the people. It’s the change management. It’s translating imprecise needs to our physicians and nursing clinical partners into what we need to do for IT. That takes a very amazing talent that’s built over time. As I lose about a fourth of my staff for retirement, how to build that in in the new generation where there’s a competition for resources with consulting firms that are trying to recruit the best talent. That’s a big threat in my opinion, against that opportunity of weaving together all this information that resides in multiple different systems and databases in order to provide better patient care across our ecosystem.

HIStalk Interviews Beth Wrobel, CEO, HealthLinc

Beth Wrobel is CEO of HealthLinc of Valparaiso, IN.

Describe what HealthLinc does.

We are a Federally Qualified Health Center. The federal government realized that there was a need to build a national infrastructure for the underserved, which up until now was the uninsured, Medicaid, and Medicare, although that’s changing.

HealthLinc was one of those free clinics back in the 1990s. In early 2000, we applied to become a Federally Qualified Health Center. We get a little bit of state funding and some federal funding, but most of our funding comes from patient fees — Medicaid, Medicare, or a sliding fee basis.

We treat the whole body. We have medical, dental, and behavioral health on site. At one of our sites, we have optometry. We have on-site pharmacies. Truly we’re a one-stop shop for those who are underserved. 

We’ve seen a huge change as people get $5,000 or $10,000 deductibles. In my mind, those are becoming our underserved. At least in Indiana, we’ve been able to get a lot of the uninsured to get services through what they call the Healthy Indiana plan. We’re not supposed to call it Medicaid expansion, but it really is our Medicaid expansion. We’re a healthcare provider that treats the whole body.

What lessons have you learned in managing health and not just healthcare episodes?

It goes down to data. A lot of times the healthcare system sees bits and pieces of that body and they don’t communicate. The number one thing that we have learned even internally is to see that person as a whole body.

I like to tease when we talk about optometry, behavioral health, and dental that we put the neck back on the body. The human body is intertwined. If you treat one part of it but don’t look at the other, you could be hurting that person’s outcome. At HealthLinc and with Federally Qualified Health Centers, we look at every part of that and help them.

The other part that is different for us is we never start with, "The patient will…" You can say until you’re blue in the face, "The patient will go get their meds. They’ll exercise." We have people that help them set goals and help them understand that. Treating the whole body and communication are the two things we do best.

What technology do you use?

We have a practice management system that talks to our electronic health record. That’s from Greenway. They have three platforms, but the one we use is called Intergy. We use it for optometry. We use it for behavioral health. It’s very flexible. We just switched to a new dental program, MediaDent, so that it talks to it.

Our medical providers can see what’s happened over on the dental side, optometry side, or behavioral health side and vice versa. It’s very common during flu shot season, which we’re just starting in, for dentists to say because it pops up in their side, "You haven’t had your flu shot. I can call someone if you want to get your flu shot right now." That’s just not heard of. It takes the IT infrastructure to be able to leverage that and to be able to do what we do.

How are you using your technology to reach out to patients?

About a year ago we got a call from The Guideline Advantage, which is a consortium of the American Cancer Society, the American Heart Association, and the American Diabetes Association. They had received a grant from the GE Foundation to work with Forward Health Group, a software company, to do population health.

That patient can look great in our electronic health record, but you can’t see what that population is going through. What are you doing? Are there things that we could be doing on a population-wide basis through this Guideline Advantage and Forward Health Group software that would improve not only that patient, but all the diabetics or all the hypertensive patients? That’s our next step in improving our patients’ health.

We’ve also found — I like to joke about this — that once we put in the PopulationManager of Forward Health Group, we were able to see data that wasn’t put in correctly. When we started looking at the population of a site and the BMI of patients in that site, we saw someone that had a 30,000 BMI, which is pretty much impossible [laughs]. It wasn’t me — that was the good news, there’s somebody worse than I am. We were able to start to clean up our data. We’re starting to do a lot more interfaces that go right in to the system and see that the medical assistant typed in the number wrong. Instead of maybe a weight of 130, they might have done 13,000. That doesn’t always come through, but it did in PopulationManager.

Our providers want to give the best care. but sometimes they don’t know what they don’t know. By looking at PopulationManager and seeing that maybe Dr. Smith — we don’t have a Dr. Smith, so I’m going to use that name — his hypertensives are not under control. We can go in there and see why. Is it the population? Is there some additional training? Something that he didn’t know? Is he using the wrong drugs?

We code everything green, yellow, and red. Green is the good — meeting your goals. Yellow is kind of, “You’re almost there.” And red. They all want to be green. When you start to show them a population, it motivates them. It gives them a better picture than what they have when they look at just each patient. That’s making a huge difference, having the TGA people working with us with Forward Health Group.

How would you describe your relationship with traditional health systems and how does the technology fit?

I used to always say we were their safety net, because the Medicaid and Medicare population and the uninsured weren’t the patients that they really wanted. We still have great partnerships. At HealthLinc, we’re pretty well spread across about 100 miles of northern Indiana, across the top of the state, and probably another 80 miles down.

We work with five hospital systems. With some FQHCs I’ve heard of competition, but we work with them more. But I could see as we start seeing these more of these commercial insurances come to us, there is the potential of that.

I have heard stories – again, I’ve never been able to document it — that the primary care aspect of a hospital system is the loss leader. They make money on everything else. My dream someday is to get a hospital system that says, "You guys are really, really good at primary care. You’re a patient-centered medical home. You have the infrastructure and everything. We’ll let you be that primary care infrastructure. You’re going to send labs and things like that to us."

From a community financial standpoint, that makes more sense to me. Of course, that’s me talking and not a hospital CEO. But looking at those relationships and what we can do to improve the health of the community, because we have been doing this infrastructure where we treat the whole body for a while now, it’s hard to catch up with that, but we’re there. So far, so good. We aren’t seen as a competition, but I could see where that could happen down the line.

FQHCs are required to have strong patient representation on their boards, which isn’t common with health systems. How does the patient perspective influence how your operation is conducted?

Patients of the clinic are 51 percent of our board. That makes a huge difference. I’ll give you an example. Before we had optometry, we had an eye doctor who would see our patients. It was in another town. There were transportation issues and things got in the way. Every time they had a no-show, they would call up. For $35, you got an eye exam and glasses. She would fund-raise on her own to pay for the glasses. 

I brought that up to the board. I said, "I’m really struggling. I’m afraid we’re going to lose this doctor. Any ideas?" One of the patients on our board said, "Why don’t you charge them the $35 up front and make them sign and if they didn’t go, they lose it?" Not that $35 is much money for someone with means, but for them, it meant a lot. Once we implemented that, the no-show rate dropped drastically. We got our own optometrist. We were able to keep that eye doctor.

Social determinants of health are becoming very prevalent now. Are you close to a grocery store? Do you have transportation? Do you have babysitting services? You can’t come to your appointment because you have to drag six kids, but Medicaid only pays for you to bring one kid in transportation? Those kind of things. They can really help us with that, too. It’s a win-win because we understand more of what it is for our patients. But everybody has those social determinants sometimes, whether you have money or not. That’s an aspect that isn’t there in primary care.

We’re open until 8:00 four nights a week, 6:00 on Friday, and open on Saturday. A lot of primary care hospital-run systems are not open that late. They want you to go to urgent care. Urgent care can take care of your urgent needs, but they’re not going to take care of your diabetes or hypertension and do your well checks.

In one of our sites that we were able to build about two years ago, we started seeing more commercial insurance patients. They’re at work and they can’t get to the doctor, but we’re open until 8:00, so they can come to us. Again, they have money. They could go anywhere. They have insurance. But because of our hours, they like to come to us. It’s bringing in what that patient needs.

Do patients who could go anywhere consider your services to be at least equivalent?

When they get through the door and they see the one-stop shop, they are like, "Oh my gosh, this is great." A newspaper editor came and we went, "Wow, I’ve never seen something this nice." We treat them with respect. We treat everybody with respect. That comes through very quickly to people.

It’s been a journey. At one time, we wouldn’t take commercial insurance. We started before the marketplace, but a lot of our patients were over 200 percent of poverty, which is $24,000 a year, approximately. When the marketplace came, they were able to get some insurance, but they stayed with us because they liked it. They felt like they were getting good care. Our hours were convenient. We treated them well. That’s important. If you feel comfortable where you’re going to your doctor, that helps with keeping you in good health, or if you’re sick, improving your health.

Where do you see the healthcare system in 10 years?

My crystal ball is broken, but I guess what I can say is that we’ve got to do something. We cannot continue for these costs to go out of control.

What I’d like to see is that every system has population health, that patients can get the healthcare wherever they want, whether it’s going to the doctor or doing telehealth. Until we get to the point where we can control the cost and use these population health programs like Forward Health Group and through the TGA, we’re not going to do that. My dream is that we will see the costs go down and that our health improves.

HIStalk Interviews Sean Carroll, CEO, Arcadia Healthcare Solutions

Sean Carroll is CEO of Arcadia Healthcare Solutions of Burlington, MA.

Tell me about yourself and the company.

Arcadia is an EHR data harmonization and analytics company. We focus on building high quality, highly usable data assets for risk-sharing entities such as health plans, IDNs, and IPAs. The scope of the business has us covering 20 million patients, 40,000 providers, and 4,000 practices, both owned and affiliated.

As for myself, I am a lifer in health IT. I’ve been at it for almost 30 years across six companies. All of those companies have had some principal focus on data and some form of disruptive technology or business model component. I’ve been here at Arcadia for two and a half years.

Your solutions connect to the back end of EHRs. Interoperability seems to have settled on two sides of the equation, one being real-time integration that requires vendor participation and the other being to extract information in some other way as needed. Do you see that perhaps the market forgets that external applications can sometimes access EHR databases directly?

Yes. That’s been our focus, certainly for the last decade — working quite deliberately on the back end of the top 30-plus electronic health record systems in the market. I think right now the standard is less about two-way operability, especially between EHRs. That’s very rare if not non-existent. But more so the kind of deep integration that is needed to execute against the kinds of measures that are emerging in the marketplace largely driven by value-based care.

Do you need the EHR vendor’s help to understand their data catalog and metadata or can you discover that on your own?

We don’t need their help, necessarily. We certainly need a customer who has invested in electronic health records to work with us to make all parties helpful to the process, because in the end, it’s the patient we’re trying to help, and it’s the customer who has made that investment who needs to drive how to get at that data to provide quality care and lower cost.

You connect to 30-plus data sources. How much information outside the EHR is needed to give you a complete picture of a patient or of quality?

Right now I would say it’s very helpful fringe-level data. Most of the market is still reconciling to the notion that deep clinical data from electronic health records is paramount to creating a high quality, highly usable data asset. We do have clients who are already well into that path, of course, and have asked us to pull in data from practice management systems or other systems that have bits and pieces of information that might not exist elsewhere.

What insights are customers discovering that they wouldn’t have been able to figure out just by looking at the EHR?

A simple example would be if you are looking at claims data — which is principally how people begin to think about analytics around healthcare data that’s been the standard for so long — you would be able to see from a claims component that someone had a cancer screening test done. But without the integrated EHR data in that analysis, you wouldn’t know necessarily whether they have cancer. If you think about where healthcare is trying to move to in terms of closing gaps in care and being efficient, the combination of those two things is what’s really needed to be more timely and efficient in how you handle the patients. That’s a very basic but I think a very important and high-profile example.

Providers often don’t know what questions to ask until they see a report that, by definition as a canned report, reflects the collective best practices of the vendor’s other customers. Are your off-the-shelf reports a surprise to providers who wouldn’t have thought about looking at specific information on their own?

Absolutely. Some of that is driven by the breadth of the information that results from that combined data set. But oftentimes with electronic health record data in the mix, you’re seeing things much more real time than you would from claims-based analysis only. They’re in a position to react to situation much more quickly through deeper and broader information that is much more timely, as most of our data refreshes every 24 hours.

EHRs focus on transaction management and data completion. They don’t do a lot on the front end with patient engagement and then on the back end some of them don’t have robust analytics. Do you see the post-EHR era being three legs of a stool with the EHR vendor providing just one?

Absolutely. The future would suggest that it’s the next generation of systems that have the capability to harmonize data from a variety of systems and draw insights from that aggregated data set. That was the original thesis for the electronic health record. Given how adoption has been less and it has taken the time that it has and the business model of value-based care and global payment is now in the driver’s seat in the marketplace, I see the electronic health record systems as a source of information among many. Albeit a very very important one and with a great deal of the necessary information, but still just a source.

EHRs were supposed to be different from EMRs because they would collect and present health information from many systems in many encounter locations outside a given provider, such as dental offices, drugstores, and long-term care facilities. That EHR concept was sidetracked when ONC decided to certify the same old EMR products and call them EHRs. Would you agree that no provider has deployed what might truly be called an EHR under that original definition?

There are unique deployments of electronic health records with unique organizations that have gotten close to the original promise of what they were intended for, but the vast majority of the market has not realized the original dream. Based on the slow march towards value-based care, we’re going to see a reset where next-generation technology is going to drop on that substantial footprint of EHRs that exist, but it won’t be the single answer. It will have to be compiled with clinical, business, and claims data from other systems to affect and support the change that’s required in the healthcare model.

Is it common now to incorporate claims data?

It’s more common. Certainly the payer marketplace is recognizing that their data coupled with clinical data is a great asset in the marketplace. About half of our clients are payers and some of the more advanced ones — like a large Blue Cross organization in New England that we work with — use aggregated claims and electronic health record data to support the administration of a very creative pay-per-performance program. That’s been very successful in bringing together providers and in the plan on the premise that if we share information carefully and appropriately, we can in fact provide incentives, control costs, and affect quality in the way that we want.

There are certainly real things happening out there with data when it comes together with the provider side of market and the payer side of the market. It works the other way, too. We have direct clients who are large provider organizations or large ACOs who are doing the same thing for similar reasons. But the concept is very much the same – the datasets together provide the lens into what’s happening across principally their ambulatory networks and they can see and manage at the population level.

Are providers are getting into the payer side of the business?

Sure. We talk to provider organizations all the time who are contemplating moving toward building a plan.

We see this in both directions, but the trend we’re seeing more is a much stronger willingness to come to the table, provided that the technology exists and there is the presence of some form of trusted third party — which is a role that we typically play — to help aggregate and arbitrage the right data to the right people in a very trusted and appropriate way. We’re seeing that trend more than providers standing up plans or plans somehow getting closer to providers.

What factors should a provider consider when choosing an analytics vendor?

It’s a very needed competency. It truly is all about the data when it comes to being effective in a value-based model. I would make sure that a supplier can connect you up with clients who’ve really put the technology to use and have seen tangible outcomes. Many organizations in the market are still early stage in the development of their technology. Secondly is the question of the source. The source in our mind is electronic health record data.

It’s very customary for us to engage in a dialog with even a medium-sized IDN who might have 50 different EHRs across their network. When you think about extracting the right data from 50 different systems just at the EHR level and getting that harmonized appropriately, it’s very heavy lifting. I would make sure that who you’re talking to can demonstrate that capability in a real way and with references.

The last piece goes back to the provider themselves. Do they have a clear strategy? Because what we’ve found is that many organizations know that they need to move in this direction and they know that data and technology in particular is important or perhaps even a backbone, but they haven’t fleshed out their full plan yet. Therefore, they’re not quite ready for the technology. That’s one of the reasons we acquired the Sage business — to help those organizations who are just a little more early stage to move closer to value-based or risk-sharing before making the investment in a solid data asset on which to drive the strategy.

How did the Sage Technologies acquisition change what you offer?

It added a deep tenure in managed care through this Midwest-based business that provides end-to-end services to provider networks that are engaged in risk-based contracts with managed care payers and ACOs. They provide everything from claims processing, network administration, utilization management including case management, customer service, data management, reporting, and critical care management. Really a full suite of supporting services that are required for an IPA or some form of other provider network to execute when they’re engaged in risk and to be good at it.

A large part of the market is still in that state, thinking about more aggressive moves and deeper risk arrangements where technology starts to become more critical. We wanted to have an ability to serve those clients now and also to make sure that we had the resident services to offer some of our technology clients in support of their activities. It has helped us with a little bit more of an end-to-end capability serving a larger portion of the market,  which is very much in transition with a variety of different maturity levels amongst the organizations as it relates to risk-based contracting.

How would you like the company to change over the next five years?

We’re very dedicated to the notion that clinical data in particular — for the next five years and perhaps beyond — aggregated from electronic health record, is fundamental to an effective data strategy. A data strategy is fundamental to being successful in value-based care. We’re focused on that.

We certainly understand the necessity to deliver on the full outcome, but our focus will remain on solving this important and fundamental challenge that organizations have, which is, "I’ve made huge investments in my electronic health record strategy. I need the information out of all of them. I need it timely. I need to be able to then process it right it away in much broader ways, including looking at the full population that I serve. That’s the only way that I will be effective in executing in any sort of risk model."

Our focus will stay there. We hope to be the recognized leader in that particular competency. We’ve been at it for 10 years. We have quite a bit of intellectual property in and around that process. Beyond that, our mission is to help patients and help the system evolve in a high quality way and to deliver to providers a useful tool that will be efficient in the way they provide medicine as these models evolve.

Do you have any final thoughts?

We’re very enthused that the market is signaling clearly that value and value-based models are the landing spot. We see that through multiple things happening with CMS, including recent announcements about supporting value-based characteristics and Medicare Advantage. That’s just another signal. We’re very curious about that. We think that that is where healthcare should be. We think we can play a significant role in assisting in that journey.

Clinical data from EHRs is a difference-maker. We’ve seen it over and over again with our 40 clients. The speed, the depth, and the comprehensiveness of that data, coupled with payer data and other sources, is critical. We  believe plans and providers can and will — and in fact, must — come together to share the kind of information that will make all this possible. We’re seeing that happen more and more in the marketplace. We’re looking forward to being a part of this tremendously positive momentum that’s occurring.

HIStalk Interviews Joshua Newman, MD, Chief Medical Officer, Salesforce

Joshua Newman, MD, MSHS is chief medical officer and GM of healthcare and life sciences at Salesforce.

Most healthcare IT systems involve back office functions that are, to patients at least, invisible at best or intrusive at worst. Do you see that changing?

We do. The proof point is that we’ve been doing it already. We’ve been doing it for five or six years. But we also see it changing because the current needs of healthcare seem to be much more around that kind of end-user experience and less about the back office stuff.

If you look at where the reimbursement’s going, if you look at value-based care, or if you just want to look at the competition that’s being caused by the ACA and all the new people with insurance and so on, you see that it’s around patient experience. It’s around consumer expectations. It’s around value-based reimbursement and outcomes. It’s about helping people take care of themselves at home, responding to their text messages, being able to send a message of support, and so on.

Johns Hopkins posted a study saying if you have a relationship with a doctor, you lose more weight. It’s just one example of how relationships, patient outreach, devices, mobility, all of those kinds of things are starting to be the coin of the realm. What I mean by that is not only are they they right thing to do for health, but they’re also being reimbursed.

What are Salesforce’s major efforts in healthcare?

You may know we’re the number one CRM company. We’ve got this very broad platform that does a lot of things. Outside of healthcare, it’s marketing, sales, and service. There’s a Communities app, which is like a portal. We have analytics and an app development platform.

What we want to do for healthcare is what we’ve done for business, which is to enable those relationships. Service Cloud is our product name. It’s like a call center app, but customized for healthcare so that everyone can have that same relationship with the patient wherever they are, on any device, to support healthcare. Not the stuff the EMR does — not medication ordering, laboratory ordering and resulting, or procedure ordering or notes — but the interpersonal communication that supports the success of those other things.

Will it be difficult for providers to make the transition from one-time billed episodes to developing ongoing, health-encouraging relationships with consumers?

It’s funny you ask that question, saying it’s the new thing. The reality is it’s the old thing. It’s the original thing we were doing before we had any technology or anything.

I was trained as a family doc. I had other faculty members, like the wise old family docs, who used to tell me not that long ago, "Write in the margins of the paper record the patient’s occupation, their kids’ names, their pets’ names.” All those things. That was the beginning of my exposure to CRM. Understand who this person really is so you can build a connection and have an impact on them.

I think because the EMRs are so focused on those kinds of fee-per-service, episodic elements, it took away a lot of that. Frankly, those systems weren’t that flexible, so it made it harder to do those things. I think now with this and with the reimbursement that’s facing it and the value of it, people are amenable to it.

The second part of your question, though, are people going to be able to do it? That’s going to be a hard thing to solve. Work flow changes in healthcare, new innovations even when they’re proven … even a medication that’s proven to be great with no side effects still takes five years to diffuse. Something like this that’s a little more complicated, that takes new jobs and new training, is going to be a little harder. Our thought is the technology is going to be able to help people do it.

What we’ve seen outside of healthcare is that when people have really good tools that make it easy to use and to succeed, they’re a little more willing to change. In fact, we see that all the time.

Just so you know, I’m not under any kind of false hope that it’s going to be simple. Healthcare changes slowly.

In healthcare we individually feel that we have a relationship from our providers and caregivers when we’re receiving care, but in that 99 percent of the time we’re not in the ED, an exam room, or a hospital bed, the faceless bureaucracy doesn’t care about us. If hospitals turn this relationship function over to the marketing department, will it feel genuine to patients or will it be like receiving unwanted calls from an aggressive telemarketer?

I’m not seeing this as like cold calls or marketing. I’m seeing this more as when you’re on your bank website, you can’t figure out what to do, and all of a sudden the chat window comes up and there’s someone who can answer your question. It feels really good.

I use an application called TripIt that brings together all my travel plans in one place. I don’t feel like I’m in a herd of cattle running through the airport. I know where I’m going to go. When I land at the airport, if there’s been a delay, I get this alert automatically sent to me saying the gate’s over here, the gate’s been changed, or you’re late, so go here or do that.

Those simple kinds of tools are available. The data is available, although the systems that own it aren’t flexible. But if you put it in something like Salesforce or any kind of modern tool, the possibility exists to make people at least feel like the system is understanding them.

That’s from the technology side, a little more of the impersonal side. Then when you want to add the idea of, if I ever have a question, I can text message a care coordinator. If I ever have a problem, I know who to call and they have instant visibility into my clinical systems; who my informal caregiver is; what language I like to speak; or what my preferences are for communications, whether it’s mobile or email or phone. Even those simple, simple things would be profound in healthcare because they don’t really exist.

It’s going to enable the kind of change of change from where I only care about my doctor and I only relate to my doctor to there’s a whole team that’s willing to talk to me, and by the way Nurse Sally is really sweet and really great and she’s the one I ask questions to because she’s willing to listen.

Salesforce and a lot of other non-healthcare technology companies scaled themselves up by opening up their systems to partners and even competitors to create an ecosystem that benefited everybody. Healthcare hasn’t embraced that concept. Do you see that changing?

Yes. I see it hugely changing. What I see in the marketplace, and what a lot of us think about is, imagine the gates or the walls that have been erected by Epic. There are throngs of companies and experts and innovators and entrepreneurs who are banging on those walls trying to get in in every single healthcare organization in every single market everywhere. They just can’t do it. Sometimes because there’s not enough patients that are using a certain service. Sometimes because the CIOs are afraid of the risk and the cost of building an EMR connection and all that. We’ve already seen it in some cases. We’ve got a use case with UCSF where they’re using a third-party decision support tool to get data collected into Salesforce to make a risk score and have it come back.

The old days of decision support tools were that you put a CD that comes from someone and you put it in your EMR. It’s usually for drug-drug interaction or drug-allergy interactions. You know about the Framingham Study, I’m sure. There’s a guy in UCSF named Jeff Olgin who’s head of the cardiology department. He’s doing an e-heart study, which is going to be a million-person Framingham Study. Gone will be the days when the cardiologist has to remember the journal article that said this or that. They’re going to start using databases of hugely valuable decision support tools. We see it at the National Cancer Institute with some of their cancer data or even this breast cancer study.

We’re moving to a time when people are realizing that a single doc with some information in their head is not enough. Allowing them to take the time to go to different journal articles and figure out what the best treatment isn’t also the best.

We look at mortgage bankers. We see that they use impressive calculations to figure out where people’s risks are. We don’t really have that in healthcare yet and I think we’re going to have it more. Then you include the device managers, you include the rehab centers and the home health agencies, and all the different people that have to collaborate.

There’s no way that’s going to happen unless there is an open system, an ecosystem, and some friendliness between parties who all want the same thing. Fortunately, the money is there and the bundled payments are going to make it a little more likely.

We really have only three large inpatient EHR vendors in Cerner, Epic, and Meditech. Does that make it easier or harder for a company like Salesforce to come in and try to open things up and collaborate outside their walls?

The irony, and it’s a little bit controversial, is the fact that there are three almost makes it like an Irish potato farm. I don’t like that analogy so much because it makes us all look like we’re going to hurt those, but we’re really not. We want to connect to them.

It makes a certain kind of standardization, and to be frank, I think the closed histories of a lot of those vendors … their strengths and weaknesses are all different, but the fact that an organization like Epic has such a mind share among the very top hospitals and yet they don’t have the flexibility to open up gives us a great opportunity to extend what they do, to connect to what they do, and to bring these organizations into a modern technology space.

By the way, we don’t have to worry about working with them directly because middleware solutions are making it easier than ever to get data out and in some cases get data back in, even if it’s in the form of unstructured text or something like that.

I suppose for CRM-type purposes, you wouldn’t need real-time EHR access or for the vendor to provide APIs to everything. You could work around that.

We can start with just an ADT feed just to identify who the person is. You’re right, we can start small. But what’s cool is at a place like UCSF, for example, they started with the ADT feed. Just tell us who they are, who’s taking care of them, and some demographic information. But then they add more data to that pipe and they’re including prescriptions and diagnoses.

It doesn’t take much. We don’t need everything. We certainly don’t need the notes. We don’t need the medication administration record. Between diagnoses and medications and maybe some lab tests, we can do a ton.

That’s how Salesforce works. We’re not like Epic where we’re going to make someone write a $200 million check or a $1 billion check. We’ll start small. We’ll solve problems with the simplest of connections and then we can move on. Frankly, there are some folks who are doing it without an EMR connection. They just use it as their engagement engine, and then over time they grow those kinds of connections to the legacy systems.

Would a typical health system CIO look to Salesforce for solutions? Is it hard to get in front of them since you’re not a traditional healthcare vendor?

If you ask me in a year, I’ll say absolutely yes. I think we’re in a transition period. There are a bunch of CIOs that I talk to who say, "Wow, I had no idea you did healthcare." Frankly that’s our job and that’s one of the reasons why we’re doing this the way we are. But there are a bunch that do know us.

It’s interesting because our pioneering customers, the people that gave us credibility and confidence that what we have is of value in the marketplace, have been organizations that say, I’ve heard of Salesforce,or I know Salesforce, or I used to be a CIO of an insurance company and now I’m the CIO of this big hospital system, I know what you guys can do and relating to my patients is very similar to relating to customers.

There’s a great quote from an academic medical center CMIO friend. He says, "We’ve got to treat our patients like customers. They’re consumers and we may treat them better than we treated them when they were patients." They know we’re useful for this and they want to customize what we have to make it work for them.

Our new product is around making those customizations built into the product so that it’s credible and relevant to healthcare. I think with the new announcement, there’s going to be a real excitement for this because people know we’ve figured out how to do a lot of this stuff.

Salesforce offers the Chatter application. Do large health systems and practices use collaboration tools as well as they should?

They don’t because they don’t have them. They know what the inbox is. One CMIO says, "We keep getting older and the residents keep getting younger. It’s really funny. My residents ask me, where’s the feed? Why do I have to use email? Why do I have to use pagers? We’re the only occupation that still uses pagers. The drug dealers don’t even use pagers."

What’s happened is a lot of these hospital systems and residents have adopted these systems just because they want to. We see the proliferation of a lot of these things that were ground-up or viral and people started using them. Then the CIO will say, "Holy smoke, what can I do here?” They use them because they just work better.

In Salesforce, we’ve gotten rid of like 40 percent of our emails using Chatter. I actually wasn’t that big of a fan of it because I use email and I’m sort of an older guy, but I’ve been convinced by what we’ve seen in Salesforce. Now we’re starting to see people in hospital systems take this up.

When we show it to them, everyone gets it because it looks like Facebook. All these kids know how to do it. They know how to do @ mentions to include other people on the feed. They know how to do other kinds of things from that feed post. Marc Benioff, our CEO, did a lot of work to make Chatter not only something that’s good for communication, but you can do links, polls, forms, fill out all kinds of stuff, and actually do your work in it.

The more helpful it is and the more it saves people time, the more they’re going to use it. We know it’s something people cotton to as an interface. To the extent that it’s helpful for their business, the uptake is going to be significant.

Where do you hope to see healthcare in the next five or 10 years?

The cues or the things that inform my answer are every other industry in the world, on one hand, and then my oath to make health better. What we see in every industry is fluid data. We see open APIs. We see hybrid information systems. We see things coming together in all kinds of ways to solve problems flexibly. If there’s a new genetics test, it should come in there. If there’s a new partner you want to work with, it should go there. If you want to get a coupon for your home health needs. If you want to have someone deliver your bandages by drone. 

Healthcare is still stuck in an earlier era because they’re stuck in this client-server technology that’s not open, that’s not flexible, and that doesn’t give people the confidence that they can safely open up to partners. I see a future where hospital systems are as open and as nimble as Amazon, Gmail, or Salesforce.

HIStalk Interviews Tom Zajac, CEO, Wellcentive

Tom Zajac is CEO of Wellcentive of Alpharetta, GA.

Tell me about yourself and the company.

I’ve been in healthcare for a little over 30 years. I’ve had the great fortune to be on this journey of transformation. My first role at Jefferson Health in Philadelphia was when DRGs first came out. I moved on to things like cost accounting and looking at efficiency of care and effectiveness of care management. 

At Wellcentive, our focus is on population health, which we’ve been doing since 2005. We don’t focus on the technology as much as the outcome. We try to help our customers drive true quality improvement; revenue growth, especially with the value-based care initiatives that are going on now; and business transformation, which is where I think the marketplace needs to be.

A Wellcentive tagline is “quality equals revenue.” What aspects of quality can be defined and measured and how should the patient’s point of view be incorporated?

Quality has historically been something of need for healthcare, but now with reimbursement, fiscal incentives are sitting there in the system to be able to drive those kind of capabilities. We have that tagline of “quality equals revenue” because the programs are now driving people to make better decisions. What are gaps of care? How can we look at patient engagement? How can we make sure that there’s better compliance for our patients to try to keep them out of our EDs? At the same time, it’s also driving them to look at better ways to focus on population health, not just on care.

The early years of my career were focused on how well we delivered care. Now with population health and this movement to value-based care, the focus has to be on how we’re treating holistically the entire needs of the patient. As healthcare organizations expand, their focus is not just on a hospital. There are multiple modalities of care among the primary care providers, specialists, urgent care centers, hospitals, etc. How do we best move a patient through that process so they not only get the most effective care, but also the best outcomes? Because it’s not just all about financial outcomes and not even just about clinical outcomes. It’s about human outcomes as well.

Is there enough incentive for providers to manage population health instead of just cherry-picking a particular metric or element they can latch onto to generate income?

You always wind up with that case. Sometimes the industry gets driven by federal mandates or insurance mandates. Typically the industry actually does the transformation. Healthcare has been very viable from that point of view. Exactly what you were saying … with some of the programs that initially come out, you’ll have a rush to revenue. I would almost make an argument some of the early ACOs were like this. Their interest was more in how to maximize revenue.

The more recent model that we’ve started seeing has an example the Delaware Valley ACO, one of customers. It’s a super ACO formed by trading partners in the Philadelphia area, such as Jefferson Health and Main Line, who are bringing together the right intentions — focus on care, focus on population health, making sure that you’re driving the best access, the best experience, and the best capability of healthcare for patients going forward. That is usurping just running for dollars going forward.

Even though a lot of these programs have been formed, we’re in a situation where organizations are forming with the right intent and the right purpose going forward. A lot of times, it’s Maslow’s hierarchy. PQRS is a perfect example. It’s a starter set, a gateway into focusing more on quality. It started out as a carrot, but now it’s starting to become a stick, and as the MIPS program is going to drive people to make sure that they’re measuring the right levels of quality.

One area we work with our customers on – and one that most healthcare organizations have to consider — is that you shouldn’t just be reactive to what programs and approaches are out there. By looking at population health, assessing data, and bringing together great analytics, you can start assessing where you operate best and how you can best treat those patients. Then use that in your dialog with payers going direct to employers to be able to set up better reimbursement approaches and better focal points.

If I were a skeptical consumer, which I often am, I would say that hospitals and medical practices could have been managing my overall health all along but didn’t until someone wrote them a check. Does population health management need to to be explained to consumers?

This is not a one-stakeholder issue. All stakeholders have to participate. We as patients have to take active participation in our health as well.

You can look at that and say that the healthcare system historically has been more fee-for-service based, so therefore they’ve only been interested in volumes. That’s not true. There are huge numbers of people in the healthcare process who’ve been trying to make sure that we put the right care together. However, now with better data and better analytics, we’re starting to be able to look at what decisions we should be making earlier. 

For a 50-year-old hypertensive diabetic, how do we make sure that they don’t wind up trending into a case for stroke? How do we get ahead of that? It’s not just the physician’s responsibility or the hospital’s responsibility. The patient has to be part of that responsibility as well, making sure that they’re complying with their treatment protocols and having active discussions with their physicians and their providers.

The one thing I worry about is the consumer or the patient being passive in this model. Nothing should be more active than your own health.

Most of what constitutes health doesn’t involve the medical establishment, such as consumers who make unhealthy choices. Are we giving providers health responsibility without authority?

Providers are now in a role of trying to also be mentors for patients to take more control of this situation. There’s a huge amount of data out there and sometimes it can be purposed in the wrong ways. A lot of the point about population health is to try to create better dialogs, better outreach, better collaborations among patients, providers, physicians, and payers as we go through this overall process. 

Hospitals are trying to focus on quality. Quality creates revenue. They also need to focus on access. They’re starting to look at where to treat patients. They’re starting to look at their markets. Where else they should compete? How should they keep an affinity with their overall practice?

For the patient, they’re trying to decide how to apply their affinity — their relationship with all of those various stakeholders — and how to get the best information. There must be a mentoring capability between providers and physicians with their patients to get the best overall outcomes.

We’re starting to hear more about the idea of consumer workflow. We focus quite a bit on physician workflow, maybe a provider workflow or payer workflow. You’re starting to see the rise of the CVSs of the world. They’re able to be successful because they’re focusing on consumer workflow — when healthcare is needed, when it’s convenient, how to get information out to patients, and how to help them focus on compliance.

Population health has to wrap that all together. It’s basically got to be able to help providers, organizations, and even payers focus on how we get the best information and aggregate information about longitudinal care, not just episodic care. Those are two different DNAs. An EMR being able to track episodic care is obviously focused on the episode. Population health has to also focus — not in conflict with — on the entire longitudinal path. What clinical data do we have? What claims data do we have? What personalized data might we be able to pick up for the patient to be able to use that to hone the best approach and the best knowledge you have with the patient? If you do that, then you’ll start to get a win-win strategy.

Employers and employer-led coalitions were not long ago seen as the best hope for influencing cost and outcomes using their purchasing power. Do they still have a role in what now constitutes trying to manage the health of populations?

Yes, absolutely. There’s been a lot of conversation, especially with the ACA, around what the employer’s role will be. Employers are still extremely important and they’re acting that way.

For example, we’ve got a customer, Blanchard Valley, who is working a care management program for Whirlpool in the Ohio area. Their role is to try to engage patients in their health. What we were just talking about before — making sure everybody has active participation. To do that, though, they’re putting in an active care management plan. They’re doing outreach, they’re following up with patients, and they’re making sure they’re complying with the visits that they need. 

It’s not just that the employers are the stopgap for the cost of health. They’re getting directly involved in that. You’ve probably read recently about Boeing’s message that they’re going to look more as an employer direct to provider or employer direct to health system to try to make sure that they create the best cycle and the best access for their patients. They are in direct dialog, for example,with Evergreen Health to be able to talk about how to best treat their patients. They continue to be active participants, but not only from a dollar point of view. 

The consumerism you were talking before has both of those relationships as well. With higher deductible plans, patients are now starting to focus on the financials and some of the decisions that relate to financials, but they also have to focus on compliance to their overall care patterns. It will impact employers and employees not only with regard to productivity, but also the well-being of their employees, which is an affinity or retention between the employee and the employer.

Are you seeing that analytics tools have improved but the underlying data are still of questionable quality?

Yes. When we start an implementation or a partnership with one of our customers, one of the key issues is trying to focus on that longitudinal DNA. Most of the larger healthcare organizations that are creating their future success are a combination of the original hospital as well as physician practices, urgent care centers, and extended care. All of that comes with disparate modalities of care and disparate data within that.

All of that data needs to be brought together and it has to be as complete a picture as possible. It can’t just be EMR data or specific EMRs and their data. It’s got to be all of the data sources that are out there – EMR, clinical, patient claims data — to try to build the richest picture that you can for those patients.

Realize that for some organizations, this is the first time they’re bringing together that type of disparate data. It’s not just aggregating the data. You have to focus on data quality and making sure it’s complete, it’s contextual, it gives you the best picture of those patients, and it’s accurate. A normal conversation I have with physicians is whether or not they trust the data they’re seeing.

Data quality is such that, as we’re going through an implementation, you’ve got to look at grabbing and aggregating that data together. Normalize it so somebody can use it in a focused pattern, and then from that point of view, figure out where the holes are.  We’re not getting allergy information. Maybe the information that we have on patient outreach is weak. How do we improve that information?

Then we can go to the quality set and look at the measures we’re trying to attack. Are those measures, in fact, giving us the right information? Are they complete? How do we now turn them into programs?

Data quality is actually a journey. Sometimes people think that integrating the data is simple and it’s going to happen overnight. More times than not, it’s a journey to try to not only aggregate the data, but make sure we’re focusing on creating the best set of data and the most complete set of data. That does take work.

What’s on your technology capability checklist when you choose your own medical insurance and providers?

I may shift that question just a bit. Let me try this, anyway. In a lot of ways, there’s been a lot of conversation about big data and analytics and the technologies behind it. Those things are important and they’re necessary for this next step, but the real importance has to be transformation.

When I look at providers or I look at health systems that I want to work with, I want to make sure that they have a comprehensive view of care management. The Holy Grail for healthcare in general is true integrated care coordination. So many of us are polychronic at this point. How do all of those things interact? How do the various physician and the various caregivers we have interact with that information so that there is a holistic view of me going forward? 

I don’t necessary look at an organization based on the technology they have, but rather the intent and the capability. It’s important to have big data and analytics to be able to drive a comprehensive approach to things like care management, being able to focus on quality, making sure we’re looking at transitions of care, and trying to figure how to best interrelate with me from a patient engagement and provider engagement point of view.

Where do you see the company in five to 10 years?

Population health has been a term. It’s turning to truly support value-based care. In supporting value-based care, Wellcentive has the ability and the intent to be the command and control across the longitudinal pattern for population health and value-based care. What we’re looking to be able to do is focus on quality programs and make sure that organizations are optimizing revenue. Focus on readmission, cost, and utilization so patients are getting the best experience. Focusing on care management and patient engagement so we know we’re getting the best compliance. Making sure that we’re combining the stakeholders — employers, payers, providers, and patients — so the communication is creating the best clinical, financial, and human outcomes that we can possibly create.

People have been saying, "We understand population health and value-based care. I’m not sure if it’s time for me to get into it." From what HHS and the commercials are doing, the incentives to move and the incentives to act are now. People have to realize that we’re losing time. We have to be able to act on value-based care now. The incentives are in place. Healthcare can be, because of what we deal with — privacy, patients, etc. — a little bit risk averse.

Really strong examples are forming on how organizations are putting care management in. The super ACOs that are forming. The trading partnerships, trying to figure out how to work between employers, payers, and other trading partners. The examples are there. Your peers are starting to work through that. This is really our time. I keep telling my staff that it’s not only our opportunity, but it’s our responsibility to drive the transformation in healthcare, and our time is now.

HIStalk Interviews Richard Helppie, Chairman and CEO, Santa Rosa Holdings

Richard Helppie is chairman and CEO of Santa Rosa Holdings, chairman of Sandlot Solutions, and founder and managing partner of Vineyard Capital Group.

With Meaningful Use implementations winding down, ICD-10 almost done, and the Department of Defense EHR bid issued, is the industry poised to contract?

No. The reason would be — anticipating your follow-up question of “why is that” — I sense that healthcare pivoting to business needs now away from some of the forced march on regulation. That is a ripe opportunity.

Which of those business needs will create the most need for products and services, such as consulting?

On the provider side, you have legacy and very well-run organizations that are designed around fee-for-service and volume. They have been constructed in the way that the business is organized, the way people are trained, the way that their IT systems are designed and deployed, and have been around fee-for-service. Those systems are mostly passive. They’re mostly tabulation systems. They wake up when there’s an admission or a registration, then they count stuff or they move a little bit of information around.

Then you have this other tower over here on the payer’s side that is also set up just for fee-for-service. It says, "Gosh, you shouldn’t have done that service that you want a fee for or maybe you should have done another service." But again, those systems — pre-authorization and registration aside — wake up when there’s a claim, then they do their thing and try to process it.

When I talk to CEOs in this industry, on both the payer and provider sides — which as you know are coming together — I pose this question to them. I ask them how many employees they have. The last one told me he has 28,000. I say, “You have 28,000 people today coming to work who don’t really know it, but they’re doing fee-for-service medicine.” One hundred percent of the time, I get the nods. “Yes, that’s exactly what my problem is.”

You’re going to see very rapid change in the next few years. I’m very excited to be part of it at this stage.

Hospitals have performed poorly in doing what’s now expected of them, managing costs and health. Will they be able to change their direction and stay on top or will new competition overcome their money and influence?

This will sound like I’m avoiding the question, but I’m not. The answer is “and both.” When you think about what that healthcare enterprise of the future is going to look like, you’ve got to have hospitals and facilities to put the very sick and the very injured in. You need to have a well-developed physician network. You need to have some kind of risk-bearing entity.

Those components are going to come out of the traditional, hospital-centered health systems who have evolved their businesses a lot in the last couple decades. Some will come out of physician groups, some will come out of payers, and certainly there’s going to be new players. As you turn to IT and you think about the confluence of those factors along with the change in the payment methods and the availability of technology, there’s going to be new players out there on the frontier for both care delivery and technology.

I’m sure other folks have views on this, I look at it around that adage that IBM didn’t invent Google. They were the largest computer company in the world. Why didn’t they invent Google? It went against their old business model. You’re going to see some of that in care delivery, in risk management, and certainly with IT.

What factors determine which technology startups will have the best chance to succeed?

It’s always going to come down to scale. Scale is going to come from distribution. Distribution is going to come from dealing with that very specific business issue.

By way of example, you see some things on the periphery that I don’t think are going to work. Somebody made a little app for the Apple watch. You say, "How big can that market be?" Well, first of all, how many people are using an Apple product versus an Android product? How many people are going to buy the watch? How many people are technologically adept to do that? It getting smaller and smaller. You go, that’s going to be an interesting project, it’s going to contribute to the body of experience and body of knowledge that we have as an industry, but it’s not going to be something ubiquitous that’s going to move the needle.

The frontier is about true interoperability. Many people have said that we have mountains of data, but what we don’t have is interoperability. We have folks that have business models that aren’t built for that, both folks that are using those systems — the traditional healthcare industry participants — as well as the vendors. Both of those have been in a fee-for-service type of mentality, so it’s not in their business model to go to interoperability.

People want to talk about interoperability. They talk about bi-directional. Interoperability is omni-directional. It’s not planned interfacing. I’m Vendor A and I’m going to go communicate with Vendor B and vice versa. Interoperability is this: I use my systems, you use yours, and our information is translated seamlessly and it’s done in real time.

The operative question that I like to ask when it comes to interoperability is this. The person you love the most is in front of the doctor. What information do you want the doctor to have? What do you want the doctor to have to do to get that information?

That’s what we have to be driving toward as an industry. Long way around, when I think about things that are going to be very successful in the future, they’re going to address that question of making all that data interoperable and in a contextually relevant way and serving it up where it does the most good, which is at the point and the moment of care.

I asked Grahame Grieve what his one wish would be for interoperability and he said it’s that clinicians would consider it a clinical problem and apply the same level of enthusiasm as the IT people. I also asked him who creates the demand and incentive for sharing data and he didn’t have a clear answer.

First of all, I love the quote. I think he’s really on to something. That’s a terrific insight.

You’ve got two questions there. Looking at it as a clinical issue, I’m chairman of a company called Sandlot Solutions, arguably the best interoperability play in the industry today. One of our physicians, who’s been a pioneer in it and is a GI doctor, says this is the most important invention in the time that he’s been practicing medicine, and he’s well into his 60s. He goes through all the different medical devices. It comes down to, when he goes to treat a patient, he knows about them.

One of his many stories is a fellow coming into get polyps removed form his colon. He’s a Medicare patient, very well organized, and he hands the physician a list and says, “Here are all the meds I’m on.” The doctor, because he’s on Sandlot, looks in his own EMR, and he says, "Hmm, I’ve got something here that says you were put on Coumadin two weeks ago, the blood thinner." He says, "You’re right. I forgot to add that to my list." That is a medical disaster avoided because of interoperability. Even well-organized patients don’t do a great job of transferring that information. I’m above average at it and I don’t do a great job at it. I’m not an MD or a DO.

That’s where the demand can come from. From doctors saying, give me a full suite of information, a full payload, and give that to me at the point and moment of care. Give it to me in my workflow. Give it to me within my EMR. You guys quit fighting. I don’t care what enterprise it came from. I don’t care what brand of system sourced it. I want to be able to know where it came from, but I don’t want to go find it. I don’t want to have to go look in five or six places for it, which is what a lot of this first wave of so-called interoperability did.

Now to your second part of your question, which is how do you get people to participate? My experience in doing this now for almost four years is that everybody wants to be first to be last. Let me explain that. If you go to any provider in Memphis and you say to any provider, we want you to connect to a system that has all the other providers in town seamlessly moving information around. Right in your EMR you’ll get all of the data from the other folks within your enterprise, and within your affiliations, and with any public health data we have. It will be delivered into your EMR in the format you’re used to looking at it.

In exchange, as you treat this patient, within the consent laws, your information will be shared. One hundred percent of people would agree to do that. That’s the barrier right there.

It’s less about incentives and more about leadership. There are some good stories forming out there about leadership, so back to your first point, who creates the demand? It’s going to come down to leadership in our industry.

What did you think about the DoD contract and what are your thoughts on how Leidos will execute it with Cerner and the other partners that are involved?

It was a very thoroughly vetted process. They certainly had the right players that were going down the stretch drive.

Everybody in the industry wants to see them be successful. We don’t want some of the fits and starts like we’ve seen in the NHS experience. I just hope that they go about it in a methodical way and create value along the way.

I do hope that they have an open mindset and enough openness in the architecture to connect to the information systems stacks that are out there. I hope that we’re able to demonstrate better healthcare for our veterans and our service men and women.

What does the future hold for Allscripts, Cerner, Epic, and Meditech?

Individually, clearly Cerner, Epic, and Meditech are the three that we see in the market doing well. All are vigorously competitive. All three have very substantial customer bases. They all have their very loyal fans. They all have the ability to engineer and deliver product. 

It’s going to be the ones that operate in conjunction with all the other technology out there are going to be the most successful. Again, I’d go back to the IBM-Google type of dynamic that is coming up in our industry.

This industry needs to start paying today’s price for IT. That’s not client server, that is cloud. Secure, private cloud, not just random cloud because of the privacy and security that we have. When those players — the major ambulatory and physician-based vendors — are truly operating in an interoperable world, open to the other data sources and places they need to provision data, especially down to the patient level, I think they’ll all be very successful.

All three of those companies are going to be part of the fabric of the next wave of healthcare. There will be other technologies that will leverage them and make them even more value, but all three of those are going to do rather well.

IBM is doing a lot with Watson. Will precision medicine have a significant impact on healthcare or is IBM just trying to find a lucrative market?

Time will tell on that. It’s a grand scheme and I’m wondering how they can bring it down to a granular level.

You asked at the top of our conversation if things were going to stall and I think not. Business requirements are going to drive IT. The question will be whose business requirement is going to bite off something that big, that complex, that far out on the edge, and that unproven?

I hope that they can move the needle and we get the best research driven to the point of care, but I see that there’s a gap between the demands of the market that I see arising today and the power of what may — but isn’t guaranteed — to come out of that collection of that technology. I think we have to wait and see.

Along those lines, NantHealth is investing a lot of money to nibble around the edges of healthcare IT. Do you think they are for real?

It’s an interesting collection of point solutions. Period.

Have you seen any startups that will be able to work their way into the enterprise?

Let me tell you what we haven’t seen. I don’t see anybody out there that is necessarily the silver bullet. I think what the industry is driving for right now is meaningful information in a contextually relevant way – both in the clinical setting and in the management of risk — and in dealing with the financial case. This is something that goes beyond the boundaries of the enterprise.

The way I look at it, there’s a continuum of that data capture. On the back end is analytic reporting. We have a number of analytic companies that are doing quite well, but they’re analyzing data that’s really bad. Healthcare has been accustomed to having data that is incomplete, developed for another purpose, and old. But now we have on one end of the spectrum analytic companies developing reports around that. Now we have better reports on really bad data.

I’ve been in the IT business 41 years and it’s still garbage-in, garbage-out. We see now the awakening for, "Let’s get to better sources of data." If one end of the spectrum is analytic reporting, the other end — the front end — is the interoperability, the capture, the curation, the collection, and the merging together of data, both at a patient level and at a population level. Between those two points, you have care coordination, referral management — both being done in very archaic ways — and care management for your chronically ill patients.

That’s the continuum that I see. I see a lot of work being done on the analytical reporting end, though I do see the folks that have been using those awakening and saying, "We’ve got better reports, but we still don’t have very good data." That’s what we have to do as an industry — connect from that source during that workflow of that actual patient encounter back through the big data analytics.

What should small companies know if they’re going to succeed in healthcare IT?

Innovation comes before standards. We have people that chase standards and regulation, and if standards ever did what they should do — which is make things cheaper and faster — it would work, but they rarely do.

I would encourage them to look more at innovation and look at a business reason for doing something versus trying to define a standard or drive a regulation and then answer that. That would be my advice to them — innovation before standards. Standards should fall out of innovation, not innovation being driven toward a standard, because we don’t know exactly how we’re going to get there.

Do you have any final thoughts?

We have a very important mission to do in healthcare. It’s not only demographic with the aging of the country, but it’s also very personal. Ultimately, this is the system that will take care of us and our loved ones. We need to make sure that we do a great job so that we have the best healthcare system possible.

HIStalk Interviews Seth Blackley, President, Evolent Health

Seth Blackley is president and co-founder of Evolent Health of Arlington, VA.

Tell me about yourself and the company.

Evolent partners with health systems and providers to support their acceleration of value-based care, which we define as providers receiving some form of prepaid healthcare or other incentives that manage the total cost of care. Our customers are generally providers, like Indiana University Health; WakeMed in Raleigh, NC; Premier in Dayton, OH; and other organizations like that. Typically they’re pursuing prepaid healthcare because they think it’s the best way to meet their mission for their patients, but they also feel like it’s the best way to steward their finances.

We generally are either supporting them with a value or risk contract with a payer, CMS, or their own health plan. Evolent is providing our customers with both technology and services in an integrated way that helps them ensure they’re hitting their cost and quality targets.

Frank Williams, Tom Peterson, and I founded the company back in 2011 along with the Advisory Board and UPMC, which is the biggest provider-owned health plan in the country after Kaiser. We looked all around the country and saw lots of software companies, consulting companies, and health plans, but nobody providing an integrated solution to help providers accelerate in this direction. We’re about 1,000 people today, working in 25 organizations. We’re an independent company listed on the New York Stock Exchange.

Surveys suggest that even those providers who participate in an ACO aren’t sure if ACOs improve quality or cost. Will the model will work?

What is definitely proven is that integrated medicine does work. If you look at things that UPMC has done over the years, or that Kaiser has done, or many other systems where you have aligned incentives, it absolutely drives healthcare value — cost down and quality up. The issue that’s an open question is what ACO models will drive the right incentives to make those sorts of outcomes work.

There’s a spectrum of ACOs. There are ACOs that have more full upside and downside incentives for providers, where they make the full investments that they need to provide integrated medicine. There are ACOs in name only. They’ve got the C and the O right, but they don’t have the A — the accountable part. Lots of those want to migrate towards a type of ACO that really does drive value.

I think it proven that integrated care works and you can drive incredible value. That’s why the markets are pushing that way. Some people are on Phase One of that and haven’t yet migrated to an ACO model that is sustainable over time.

We’ve created a health system based on the premise that provider competition is good, but many of the hot issues such as interoperability and integrated care try to force those competitors to work together. Will the competitive pressure go away and allow those things to happen?

The direction that CMS and the buyers of healthcare are pushing for is to have healthy competition that will create alternatives for consumers and buyers to purchase networks and products that are higher value. That kind of competition is healthy. What it will cause at is providers and payers to look at each other differently and find out the right way to configure those networks.

The organizations that may have been competitive in the past may become partners and vice versa, but we have to continue letting that evolve such that we do have healthy competition of selection choices of different provider networks and different tiered networks. The buyers of healthcare will have options and the volume in healthcare flows to those payers and providers who are creating value. We’ll have more collaboration areas than we’ve had it in the past, but we still want the competition over time that’s set up around the right issue, which is the total cost and quality of healthcare.

You mentioned UPMC, which is a key player in the western Pennsylvania market where health systems bought insurance companies and vice versa trying to control the market. That may have been a preview of what we can expect as health systems and insurers try to maintain their business. Is it constructive for the big to get bigger?

Without speaking to Pittsburgh specifically, what will be constructive is if the buyers of healthcare — and CMS is really leading the way here with this 50 percent target by 2018 under true value-based care, but then also their value-based purchasing bundles, the doc fix — all lining up the structure where you really on the provider side will only get paid well if you’re creating value over time. If the market continues to move that way, whether you’re big or small, you’re going to have to create value in order to have a viable financial structure as a health system. That’s the biggest force that we see happen.

I do think that FTC and the DOJ and whatever markets will continue doing their work, both on the payer side and the provider side, which they need to do, but generally, the structure of value-based reimbursement is probably the most healthy thing we have to kind of make sure we end up with a cost and quality outcome that’s attractive to people who are buying healthcare.

What will hospitals look like in five to 10 years?

Our view, from an Evolent standpoint, is that there’s going to be some winners and some losers over the coming years in the health system space. We feel that progressive health systems will increasingly become entities that provide a very broad set of services and that ultimately take accountability for the total premium dollar all the way back to the buyer of healthcare. That includes acute inpatient, outpatient, and probably more primary care and more care management and population health services than they’ve had in the past.

We see a lot of those systems investing more heavily in those types of services that help manage the total cost of care then they do in new bricks and mortar. As an example, the things that are part of the premium, like pharmaceutical costs that we see health systems investing more around, “How do I manage the total cost of pharmaceuticals?" which traditionally hasn’t been part of their purview.

We think those many systems that are going to be the winners will continue to invest in that broad spectrum in ability to take all that, coordinate it, and offer something back to a buyer of healthcare that is attractive. We think that there will be a swath of systems that move that way. There are some systems that, if they don’t move as fast, may be boxed in a little bit more in terms of the spectrum of services they offer. Those will have a harder time financially than those that attempt to move upstream and take on a Triple Aim approach to healthcare.

Health systems haven’t had much interest in managing consumer health and haven’t done a good job holding down costs, and yet now they’re being appointed as the best hope for doing both. Will it be a challenge for health systems to move quickly away from transactions and filled beds to managing health and costs?

We do think it’s a big shift. It requires a lot of new competency and new capability. It’s the reason we created Evolent as an acceleration partner for those health systems as they build up their own talent and their own infrastructure around this. We think they can benefit from a partner like Evolent to provide the expertise in these areas where they’ve had less of it in the past. Things like our Identifi technology platform that is purpose built to help optimize their EMR investment in order to do this work and take an EMR investment which historically was more focused on the areas you asked about and make sure it’s optimized to do things that are going to be critical in this new world.

There are all kinds of issues. One example is risk adjustment, which is a really important issue for the exchanges or for Medicare Advantage that traditional health systems haven’t had as much exposure to. Or managing pharmaceutical costs. Just generally coordinating care and prioritizing outreach to a patient who may not be in their hospital or in their physician practice on any given day. Our Identifi platform is one example of what we bring to the table to help them make that pivot.

Your description is very accurate. It’s a big leap to go from here to there. That’s where we’re focused in supporting them.

The EMR is becoming less he center of the universe and is getting walled off by other technologies that are just as essential, just in different ways. Is there a market outside the core EMR business and are people paying enough attention to using them optimally rather than just buying them?

We’ve seen most of our health system partners betting deeply on the EMR as a critical part of their future. We’re spending a lot of time helping them make sure they’re getting the most out of that platform and leverage and identify to do that in concert with the EMR.

That said, most of our partners have networks that may be very broad. We have one partner that working with that has about 40 different EMRs that are relevant across their network. Being able to integrate and optimize population help across all those is critical. Having all the clinical content and knowledge about how to do population health is another thing that we’re bringing to the table through Identifi. We see other companies doing similar work.

In answer to your question, people are betting on the EMR but also realizing that they need to supplement it to be proficient at population health. We are trying to help them in both of those ways.

What are the most important characteristics of a provider that is well positioned to succeed under value-based care?

The things that we see that are critical are that the health system leadership has a vision that, over time, having a value-based structure is the best answer from a mission standpoint for their patients and is the best way to steward their financials. Those that get that and believe that or feel like the world’s headed that way is probably the most important thing.

After all, you can develop additional assets. You can develop your brand. You can develop more physician relationships if you start with that and you’re committed to do it. That’s probably the first and most important thing.

Obviously having a physician network, particularly primary care physicians, is, also a critical asset, so we look a lot at that. Many of the things that go beyond the leadership and the physician base can be developed over time.

One thing that we see a lot is that health systems, at times, need support in helping understand the full array of capabilities and competencies that they need to be successful. We do a lot of that in the Blueprint process. It’s not just about technology. It’s not just a consulting project. There’s a broad set of services and technologies that they need to make the pivot, as you articulated. It’s a new frontier for many of them. We try to bring that depth and understanding during the Blueprint as well.

Where do you want the company and the health system to be in five to 10 years?

Like many of the systems we’re working with today, I hope that there are systems in every market across the country that have a vision and a plan to execute on an approach to take the value-based model and make it a core part of their business. Not a pilot or initiative, but a core part of the business. That’s certainly where CMS and the payers are pushing.

We hope they have that in place. We hope that they’re the ones that do it and are the market leaders, able to gain market share and have a stronger financial position than they have today based on that strategy. You can see that happening today and a number of our partners are getting great outcomes out of the gate. We’re hopeful that that spreads and scales nationally and that they’re successful as part of it. As a result, the patients they’re taking care of are getting better care at a lower cost. That’s where our mission lies and where the missions of our customers lie as well.

Do you have any final thoughts?

We increasingly see that the future direction for payers and providers is pretty clear. CMS and the other payers are speaking clearly about where they want the market to head. We feel like that creates a huge opportunity or risk for the provider. If you can move and be a market leader, it’s a huge opportunity, and if not, it’s a risk.

Our experience with IU Health, WakeMed, Premier, and MedStar is showing, already over the last few years, that they can both do better financially and do better for their patients if they’ve got the right support. Evolent is uniquely set up, based on our heritage, to help them do that.

HIStalk Interviews Todd Johnson, CEO, HealthLoop

Todd Johnson is CEO of HealthLoop of Mountain View, CA.

Tell me about yourself and the company.

I’ve been in healthcare IT for 18 years. I joined HealthLoop about two and a half years ago. HealthLoop is a patient engagement platform designed to guide patients in a really high-touch way through an episode of care.

The company is built on the premise that no news isn’t really good news when it comes to patients who are recuperating, managing a chronic condition, or not scheduled for an office visit soon. What are providers learning as they use technology like HealthLoop’s to keep in touch with those patients between encounters?

There’s an incredible amount of information to be learned from patients. In general, patients are the most underutilized resource in healthcare. A patient is discharged from an emergency room or a hospital or from a physician’s care. We give them instructions and expect that they’ll do really well, but we have no idea.

With today’s patient engagement platforms, you can understand how a patient is progressing the first day, the second day, the third day. You can understand where they’re having challenges or where they’re adhering to the care plan. Care plan adherence is a really interesting opportunity to understand our patients participating in a way that’s going to lend to the best outcomes at the lowest cost.

Does ongoing communication make patients feel empowered or more closely engaged with the provider?

Absolutely. What we’ve seen is that patients genuinely appreciate this level of service.

The healthcare system in general provides a pretty poor product. We’ve optimized around transactions. We’re always solving for throughput and decreased length of stay. The result of that is we’ve been discharging patients and they don’t get a lot of information.

This sense that patients have their doctor with them, monitoring them every day, is incredibly powerful. In fact, we see it every day. The first email I open every morning lists all the positive and negative sentiments we get from patients about this experience. It’s a wonderful thing to see how thrilled patients are with this level of service.

Patients get high-touch, high-feedback engagement, but there’s no overhead for the provider unless they need to take action since it’s an exception-based system, correct?

Exactly. It’s really a win-win. We’re doing a study right now with a large academic medical center in oncology. There’s a lot of noise coming into practices from patients that either don’t understand their instructions or are unsure. If you’re delivering the right information at the right time, indicating what the patient needs to be doing today, you not only drive comprehension through the roof, but the early results — and this will be published hopefully later in the year – are that patients have a 45 percent increase in just understanding their instructions and their care plan. But what’s better is that reduces unnecessary phone calls back into the practice, the questions, “Can I do this, can I do that” sort of thing.

It’s shifting to what we call exception-based medicine. Focus on the patients that need your attention.

Traditionally, we have a schedule with patients. We’re all in love with what’s happening in orthopedics right now based on what CMS has signaled. Traditionally, the patient gets discharged and then you might have a structured follow-up at two weeks or four weeks and then eight weeks. But really, it’s about monitoring the wound and monitoring adverse signs and symptoms.

If patients are doing fine, there’s no need to bring them in if they’re progressing normally and healthy and everything’s well. But if a patient’s got severe calf pain or early signs and symptoms of an infection, you’ll want to get that patient in earlier at Day Seven or Day Eight so you can mitigate the expensive emergency room visit or hospital readmission.

Beyond the desire to do the right thing, what is it that motivates health systems and practices to want to provide that experience where they are keeping in touch with patients in a manner that’s not entirely episodic?

I wish that wanting to do the right thing drove more decisions on P&Ls, but the economics of healthcare is such that you really have to focus on dollars and cents. If you look at the trends in episodic bundling, there is a huge movement that is going to put an increasing pressure on health systems that aren’t carefully monitoring their patients and engaging their patients to provide the best care at the lowest price. Patient engagement is the tool that needs to be used to do that.

We’re learning a tremendous amount of data on patients. What is rising as a crystal clear indicator is that patients who are highly engaged do absolutely have better outcomes at lower costs and they’re thrilled.

Who are your competitors and what are they doing to try to solve the same problem?

I put competition into a couple of categories. The worst is the status quo. “We’ve been doing it this way forever. We don’t need to invest in new capabilities and new technologies.” In medicine, the status quo is tricky. But if you look at the large health system that’s paid $300 million or $500 million for their Epic system, it takes a lot for that CIO to make the decision that it’s now time to bolt onto that and incorporate patient engagement technologies that are then additive and go beyond what you were hoping to get out of a single vendor.

That’s the stiffest competition. But we’re seeing a constellation, all sorts of really clever and seemingly great patient engagement applications out there. There’s not enough of it to feel like a direct threat, but I do think that this is probably going to be the next blockbuster product category for health systems.

Does the provider need to log on to your system to see those patient messages or is it integrated with EHRs?

For the Epic platform, we’ve got seamless integration. On the patient side, the notification to check in today is delivered through MyChart and the patient can complete that there. O the professional side, if a patient escalates with a DVT risk or an infection risk, that that further escalates within the Epic inbasket and then the entire HealthLoop experience is both documented and accessible through Epic. We’ve been very deliberate about integration with that particular system.

Then of course HealthLoop also operates on a standalone mode. We’ve got 40 or 50 independent practices that are using that in a standalone way seamlessly. We’ve taken a Silicon Valley approach that you can get up and running literally in days. We had a health system go live with a program in seven days from contract signature. It doesn’t need to take forever to get this stuff up and running.

How does the Silicon Valley atmosphere impact the way that HealthLoop does business?

One of the most special things about Silicon Valley is the design thinking. The designers here think about, how do you make technology habit-forming and invaluable to individuals? It’s something that is blatantly missing from so much of the health IT out there.

I was at a board meeting with a bunch of clinical chiefs from all these different departments at this large health system. For 20 minutes, they sat around looking at the screen trying to figure out how to visualize their EMR in a widescreen format and how they should move things around, which is just remarkable to me.

Silicon Valley is focused on, how do you make technology delightfully simple to implement? Up and running, no manual, and fast so you can see value quickly. You actually feel the value.

A couple of things that we’ve done in HealthLoop have demonstrated that once you get this in physicians’ hands, they’re really, truly delighted by it. They’re learning more about their patients than they’ve ever known. They feel good because they’re getting constant reinforcement, validation from their patients that this is the right thing. I don’t think that many physicians or other healthcare providers really feel good about the technology they’re using in a day-to-day basis.

Will consumer expectations push large vendors to think like Silicon Valley?

Folks in general want to tap into what’s happening here in Silicon Valley and understand what’s going on. But increasingly as health systems mature in their implementations of their electronic medical records, they understand what they need to do to add on to it and to be additive. With the large EMR providers, we’re seeing some signaling on this. I’m not sure how committed they truly are. But singly to open up their platforms and allow for innovation to occur, which would I think further concrete their long-term position on the market if they can be open to that type of innovation.

Have you measured the outcomes health systems saw after implementing HealthLoop?

We have. We’ve seen a tremendous drop in readmissions for total joint replacements, a 33.7 percent drop, which is material. On the patient satisfaction side, we’ve seen a 9.6 percent improvement in HCAHPS. HCAHPS is a complete survey with a whole bunch of assessments.One is how thrilled is the patient with their doctor, and a 19-point improvement there.

One of the surprising things or perhaps biases that people have when they first get introduced to HealthLoop is this misperception that older patients won’t use technology. We’ve found that to be just the opposite. The 60- to 70-year-olds are most likely to be 100 percent engaged. Even 63 percent of 81 and older activate their accounts and routinely engage. Patients want this, patients are ready for this, and when they engage, good things happen.

Technology usage is often stratified by income, educational level, and geography so that a company’s great ideas don’t reach the most expensive patients. Have you determined whether that target audience is easy to reach?

We’re seeing that activation and engagement rates hold with chronic disease patients, but not for long periods of time. We’re focused on acute episodic flare-ups where we can have an impact in providing a great degree of education during those flare-ups.

Across socioeconomic barriers, we haven’t seen an impact. What does change is modality. You might be using a mobile phone as opposed to a traditional desktop computer. Consistently we see young men are the worst engagers. The 18- to 25-year-old males are the ones least likely to be 100 percentage engaged in HealthLoop. They’re the invincibles.

Funding comes with an expectation for growth. How will you scale the business up?

The good news is that the payers and principally Medicare are creating all the right incentives for accelerated growth. For instance, with the comprehensive care for joint replacement payment program put forth by Medicare last month, not only is it the incentive to do better than your peers and continue to improve outcomes and decrease costs, but bonuses for collecting patient-reported outcomes, which is almost a side effect of using HealthLoop. We capture all those structured PROs as well. I think we’re going to see rapid growth that follows payment programs that incentivize that. I think it’s going to be a lot of fun. We’ve got a lot of good work in front of us.

Do you have any final thoughts?

It’s just an incredibly exciting time. Patient engagement is absolutely going to transform healthcare in a really great way for the ultimate consumer of healthcare, for patients. It’s fun to see that come to life every day. We enjoy our job and we enjoy working with our customers. It’s fun.

HIStalk Interviews Scott Bagwell, President, Experian Health

Scott Bagwell is president of Experian Health.

Tell me about yourself and the company.

I’ve been in the HIT industry since the late 1990s. I’ve been through a dozen acquisitions on both sides. I started out with a small company in Charlotte called Systems Associates, Incorporated — which was the SAINT hospital system — that was acquired by American Express, which became First Data, which sold to HBOC, which became McKesson HBOC. I stayed through all those acquisitions. In 2000 I went to Sunquest in Tucson, acquired by Misys Healthcare. I then went to NDC Health in Atlanta, which was mainly a healthcare claims and pharmacy transaction company, including analytics. That was acquired by PerSe, which was acquired by McKesson, and I ended up again at McKesson. I left there in 2010 and came to Passport Health Communications, which was acquired by Experian.

What is included under the Experian Health umbrella and what’s changed since Experian acquired Passport?

I came to Passport in 2010. My former boss Scott MacKenzie and I had worked together for 10 years at McKesson, NDC, RelayHealth, and all those McKesson companies.

Passport was known primarily in the early days for patient access, focusing on eligibility, address verification, those front-end components of the patient access solution. We eventually became an integrated workflow. We replaced multiple point solutions in hospitals and physician offices. In the patient access world, there could be as many as seven different vendors on the front-end process. We developed a platform called eCare Next that integrated all of the front-end functions, from ordering, scheduling, eligibility, address verification, patient estimation, quality control, and payment systems, including claims and management.

Experian Health originally acquired Search America in 2008. Search America had a strong presence in about 900 hospitals, primarily providing payment prediction services, correction software, and address verification. They were also focused on data analytics. That was Experian’s first venture into health. In 2011, they acquired Medical Present Value, which is primarily focused on physician practices. It was an Austin, TX and San Antonio-based company providing services for physician practices in large academic medical centers for over 75,000 doctors,  focused on improving reimbursement and payments from commercial providers.

That was 2011. That was Experian Healthcare. Then in 2013, Experian acquired Passport. We had a strong presence in both hospital and physician markets. Our products were focused on front office efficiency and an integrated workflow management system. Our guiding principle at Passport was payment certainty. Our systems were designed to find a payment for patient, no matter whether it was charity, Medicaid, Medicare, or third party. We focused on that guiding principle of payment certainty for every patient.

That’s who Experian Health is today. It’s a combination of those three companies: Search America, Medical Present Value, and Passport Health.

Passport was a fairly quiet company that sold for $850 million. How does a company position itself for success in ways that might not be obvious?

Passport began in the mid to late 1990s providing Medicaid eligibility systems. At its heart, it was really a technology company. It’s those roots and that focus on technology that allowed us to evolve into SaaS. We’re a SaaS solution today. That allowed us to begin to integrate those disparate modules into one integrated workflow. Our core value is client driven, first and foremost. Focusing on the customer. We believe if you focus on the customer first and foremost, everything else follows in line.

Technology was the enabler that we had in place. We had some really smart people at Passport. We encouraged teamwork. Consider the source, but I think it’s one of the best collections of employees that I have ever worked with, really dedicated to our customers. We are somewhat maniacal about customer satisfaction.

We are in a tough market. Tough with all of the variables that we deal with, but we are very metric driven. Every function that we have at now Experian Health — we began this at Passport — we measure. We measure the user experience. We get automated reports showing how our customers are actually using our products. The ultimate goal is to help those customers optimize our products and solutions.

Customer driven first and foremost, high-performing teams, and then the metrics –measuring how we do. Never, never, ever achieving “becoming good enough” because we always know there’s room for improvement.

What is the biggest change for providers trying to collect the increasing amounts of patient responsibility while maintaining their satisfaction scores?

It’s tremendous change with uncertainty over financial responsibility, the fact that a patient can’t know in advance what their service is going to cost them. There’s increasing ownership and involvement by the patient to become more engaged in that part of the healthcare system. There’s a need for transparency.

We developed a patient estimation solution several years ago. It is one of the most widely deployed out there. It’s part of that integrated workflow. The uncertainty of financial responsibility, both from the provider and the patient perspective and the payer as well, and then that need for transparency. Part of what we focus on and the challenge that we see is how to optimize performance in the midst of the growing out-of-pocket fees and the decline in reimbursement for our customers.

Reimbursement seems to have diverged, where on one end patients are expected to pay for their specific services in cash, while on the other end value-based care makes charges mostly irrelevant. Is it a challenge to deploy technology to manage both?

Yes, it absolutely is. There’s a blurring of the lines in a trend that’s moving quicker from providers to the payer side with this value-based reimbursement model that’s gaining strength in the marketplace. There definitely is a blurring of the lines. 

In post-acute care, the patient goes into a black hole today. There’s a coordinated care document in a hospital, but it rarely follows the patient. In order for the payers to bill for bundled payments, for the providers to understand what payments they should be getting, we think there’s some common good in there. We believe we’re in particularly good position to do that today. That’s the part of the growth strategy that we’re focused on right now. How we can help with that whole value-based reimbursement world, both from the provider perspective to the payer. The bulk of our business is with hospitals and physicians. We have a number of payers, but we’re a pretty provider-centric organization today.

What drives you crazy as a patient when you experience your provider’s revenue cycle first hand?

I like to know that my bills are paid. The fact that a provider would take so long to get the bill back … I just think it’s crazy to wait 60 to 90 days for the providers to get paid.

At NDC, we worked in the pharmacy transaction world. It’s a simpler transaction, but the standard in the pharmacy world is NCPDP. When we were at NDC, we used to wonder why we couldn’t auto-adjudicate for hospitals like we did for pharmacy. Granted it’s greatly more complex, but why can’t we get there? To this day I wonder why we can’t get there. We had a number of initiatives and we thought we could pull it off, but it still hasn’t happened.

What opportunities and threats do you see for provider revenue cycle?

Wherever there’s a threat, there’s typically an opportunity. Our goal is to encourage greater patient engagement. We are working on mobile applications for mobile access to our applications today. Maybe not schedule an appointment, but why can’t you request an appointment? We’re looking at greater patient engagement. We engage our clients in client-driven innovation. We’re in almost 3,000 hospitals today and we work with some of the largest systems in the country. They drive us. We like delivering client-driven innovation.

The other thing that has been one of our guiding principles is touchless processing. I talked about being metric driven and how we measure everything we do. We look at the customers who are coming closest to achieving touchless processing. You’ll never get 100 percent touchless processing, particularly in what we do in the patient access-revenue cycle world, but 85 percent of the time, we believe a transaction could go through our integrated workflow. We think that’s the ultimate goal and we’re continuing to drive to that.

We’re not there yet. We’ve got some large customers who are achieving 80 percent touchless processing, so the workflow just goes through.  The hospitals only touch the exceptions in the process. That’s where we think the opportunity will continue and we’re focused on delivering it.

Do you have any final thoughts?

I’m pretty proud of the company. We achieved #1 in KLAS last year. That in itself is a challenge because people will tell you the only way to go is down. We’ve had a contest among every department to see how we not just live on last year’s laurels, but how we can improve our customer satisfaction scores. We really are focused on that. We’re just announcing the winners. Every department, every functional part, sales and marketing, the sys ops, the devs all had nominations to see how they could personally improve our customer satisfaction scores. We’re pretty proud of what we’ve done. We’re not going to rest on our laurels moving forward.

HIStalk Interviews Mari Poledna, Telehealth ICU Nurse, Banner Health

Mari Poledna, RN is a telehealth ICU nurse with Banner Health of Phoenix, AZ.

Tell me about yourself and what you do.

I’m a telehealth ICU nurse. I work for Banner. I have been in this position for seven years. I have 18 years of ICU experience. I monitor ICU patients throughout the Banner healthcare system, following the model and the protocols that we’ve developed throughout the years for providing bedside monitoring and services for our sickest patient populations.

What’s it like to be working on the tele-ICU side of the house after being a bedside nurse?

In my heart of hearts, I am, I think, a bedside nurse. I still do some bedside nursing to keep my skills as clinically accurate and up to date as I can. I find that the challenges for me are to keep myself focused on how I can best support the bedside nurse and the patients in their hospital stay. I’m always trying to think like the bedside nurse.

Nurses glean a lot from their familiarity with the patient and how they are behaving. Can you do that as a telehealth nurse?

I have found that at this point in my career, with having the experience I’ve had — 18 years of seeing patients with all acuity levels — that with a video camera, honestly, I can video camera, look at a patient, and within a minute in many instances, I can tell that patient’s in trouble and that patient’s not going to last very long in terms of how they’re doing and what their physiological status is.

I feel in that sense that I can definitely get a good sense of how patients are doing. I don’t have to focus on the minutiae and the tasks of getting the things done. My viewpoint is different than what they see at the bedside, but it’s sometimes a really, really important vantage point. If you’re looking at something really up close versus stepping a few feet away, you’re still looking at the object, but you may see things that you didn’t see before.

A bedside nurse has to worry about the minutiae. They have to worry about the tasks, managing their time, other patients that they’re responsible for. Sometimes you’re just so busy and the patients are so much more ill now than they were when I started in ICU 18 years ago. Half the patients I see now in ICU would probably be dead, in all honesty. They’re very, very sick. So yes, I can look at a patient and a lot of times be able to see there’s going to be a big problem here.

The bedside nursing model seems to fluctuate every few years, with nurses first doing only clinical tasks at the top of their license, but then being made responsible for everything down to emptying patient room trash cans and sweeping floors. Now that you’re isolated from those non-clinical tasks and can concentrate purely on the intellectual activity of being a nurse, does it seem that the model is wrong?

I still do some bedside. I am emptying my trash and I’m doing certain things that other non-licensed people could do. Once again, it’s a budgetary focus, and a lot of times, the things that get cut are the things that they figure, hey, nursing can do that. We’ll just have nursing do that.

The trickle-down effect is that they’re not having the time to sit and look through trends, values, and labs. I can do that. If I see a patient and I’m worried about them, I can spend as much time as I want, 15 or 20 minutes, and look through the chart, look through results, and pull up strips. I have time to come up with a picture and a situation.

When I’m at the bedside, a lot of times I’m in this frantic mode of doing. I’m doing, I’m doing, I’m doing. Sometimes I have to stop myself and go, wait a minute, let’s think for a minute. What’s going on with this patient? What do I need to focus on right now?

I think I have a distinct advantage in that I’m still doing both versus some of the folks that I’ve worked with who are only doing the telemedicine side of it. I can see how you become more out of touch with that bedside experience. You become a little more out of touch of what they’re trying to do and what their challenges are. I like being in touch. I want to be able to be that person who can say, I know what it’s like at the bedside — I still do it.

Tell me what your day looks like.

My day will start with getting an assignment of approximately 45 patients in five to seven facilities throughout the United States. I’ll come in and I’ll pull up all my technology, which is Philips monitors at the bedside. I pull up the electronic medical record that the nurses have at the bedside. Then I pull up three different applications that help me monitor the patients. One is just alarms and vital signs. If anyone’s vitals — heart rate, blood pressure, oxygenation — goes out of range, I get a notification for that. I have one screen that’s just a video camera that I can quickly access if I want to look into a patient’s room. 

Then I have our version of an EMR. It’s not part of the patient’s medical record, but we use it to admit our patients and create a profile. Our electronic medical record has vital signs, trending, and basic labs. It’s a quick snapshot. If I tell a physician, "Please look at this patient," they can pull up a screen and have a quick snapshot of everything they might need to look at for that patient.

I start out by doing rounds, much like the physicians go in and do rounds. I look at the chart. I look at recent vitals, the labs for the day, I will video camera in a room and look at the room, look at the IV pumps, look at the oxygenation, look at the patient’s general condition. How do they look? Have they been stable? What are their hemodynamic drips? What are their oxygen requirements? Are they safe? Do they look comfortable? That takes maybe five minutes per patient. If I see issues, if I see holes, if I have questions, I’ll go and delve a little bit deeper into that patient’s chart. Then I move onto the next patient.

I’m doing my rounds, and as I’m doing that, new patients will be coming in the system. I have to quickly assess, how sick is this patient coming into this bed? Do I want to send the message to my doctor and say, "I’m getting a really sick patient into this facility — please take a look at this patient." Or is it a relatively stable ICU patient that I can put them in the system and just keep an eye on them? You’re looking at alarms. If I see what we call the red alarms, which are the most acute values, I might have to click into the Philips monitor and say, that oxygen says it’s 80 percent. Is that really true, or could that be the patient pulling the monitor off their finger? There’s a lot of false alarms. I’m sure you know what alarm fatigue is. That’s a big problem in these monitor units.

When I see critical situations, I have to look at that and go, do I need to look at this right now or is this a false alarm? Your whole day is rounding. It’s answering alarms and looking at patients. Sometimes the bedside will call us and ask for a second med verification, or we can actually verify blood. Our video cameras are so specific that I can zoom in and read a patient’s armband. I can zoom in and tell you where an endotracheal tube has been taped at the lip. If you have a nurse with a flashlight in the room, we can check pupils. We can look at anything in that room, even to the minutiae.

If you find something wrong or need to communicate with other ICU nurses or intensivists, what do you do?

A lot of times, if something really serious is happening at that point, if there’s someone physically in the room, a nurse, I’ll be talking to them. If not, I’ll usually ask one of my colleagues, hey, call over to this facility, tell them to go into Room 12.

Let’s say it’s a patient who’s hanging out of bed. They’re going to fall out of bed. We get a lot of that. Confused patient, they’ve just pulled out one of their lines, they’re bleeding all over the place. If it’s a nursing thing, I have someone else call the actual unit and I usually stay with the patient virtually — I talk to them. Believe it or not, they’re actually very receptive if we direct them, “Don’t put your other leg over the bed.” We tell them what to do or what not to do. “Put your oxygen back on” if they can physically do it. A lot of times they’ll actually do what we ask them to do.

If it’s something very serious where they need a physician, we have instant messaging to our physicians. I’m in Phoenix, they’re in Los Angeles, they could be in Tel Aviv, Israel. Sometimes, they’re in the same core that we’re in here in Phoenix. Sometimes I’ll just walk over and say, “Dr. Shah, can you go into this room right now?” Or we’re all up on instant message, so I can instant message them, and within seconds they will be able to turn their video camera on and go in the room and assist with whatever situation is going on.

In the Banner configuration, are you an extra layer of eyes and ears or have they taken nurses away from the bedside and moved the coverage to the tele-nurses?

No, they haven’t. They have not taken anything away from the bedside. One of Banner’s main initiatives is to become a leader in this industry of innovation and telemedicine. They’re using a lot of their resources. 

We’re finding that our results are great. We’re saving money and length of stay in ICU patients. We’re bettering our morbidities and mortalities by this service. No, the nurses don’t have to do anything extra. They don’t take on extra patients or extra responsibilities. We used to refer to ourselves as a second layer of care, or second pair of eyes.

Do the bedside nurses see you as a Banner colleague who happens not to be sitting there or do they have some resentment that you’re overseeing them from afar?

Initially there was a lot more resentment, I think because the education that we provided probably wasn’t as much as it should’ve been when we would first go into a facility. What we learned was if we’re going to be providing a service, it’s really important for us to go there, spend several days, meet the staff. Really educate them, explain to them that we’re not watching what they’re doing. 

We’re not looking for mistakes. We’re not micromanaging what they’re trying to do. We’re just here. If I see something that maybe for whatever reason I’m not sure if they’re aware of, or I have a concern, I approach it like, "This is something I noticed. Do you need some help? Can I get an order for you? Do you want my doctor to come in and assist you in this situation?”

Here’s a brief example. Doing my rounds one morning, I noticed an oxygen level was at 70 percent for a patient. Normal is 93 to 100. I went into the room to take a look. The respiratory therapist and nurse were in there and the patient had a tracheostomy. They were using a bag. They were bagging the patient and trying to get the oxygen levels up. They were all working very hard, but I could see that the patient was not responding. I could see the patient had had several of these episodes in the past. I said, "Just coming in to check on you guys. Can I send you my doctor? Do you need some help?" One of the nurses said, "We were thinking about calling you." I said, "No problem. Let me have my doctor come in."

When our physician went in the room, he could immediately see the patient and what was going on and see that the patient was not being able to be ventilated. He gave several medications. He paralyzed the patient, gave sedation. He spent a good amount of time to get the patient in a condition where he could be ventilated because the patient was having some heart problems with his oxygenation.

They were doing what they knew to do. They were doing the right thing, but the patient needed more. What the patient needed was an expert physician who understood how to treat this patient. We were able to prevent that patient from coding because they were going to head in the direction of a cardiac arrest. That was a great idea of how I was able to go in and say, "Can I help you?" and they said, "Sure. What can it hurt?”

They’ll think about us, but they’re in the moment, they’re treating the patient. “Oh, I better call the primary care doctor and get some orders,” but in that situation, there really wasn’t time to wait for someone to respond to a page or come in. At my workplace, we call that a save. Our physician did some extensive interventions. We were able to save that patient from deteriorating.

Do you document in the electronic health record?

We do. If we have interaction, there is a special form that’s been developed into our electronic health record. We used to be called iCare and it’s called an iCare intervention form. If I have a discussion with a nurse or I see something, then I’ll put a quick note stating what I observed and that I spoke to the nurse. It will direct me to, did I escalate it to a provider or am I just going to continue to monitor the patient?

We do put our stamp in the medical record when we do some interventions or we have conversations. We need to be able to validate how we’re contributing to the patient care. That’s an important part of our job that they’re having us focus more on. It’s like, if you’re doing things, if you’re assisting with things, make sure that you make a note. We do that.

How do you see more generalized types of video visits fitting in with in-person clinician visits?

It mirrors where we are technologically in our society. Ten years ago, I don’t think any of us thought we would be able to be on the Internet on our phones. That seemed like a strange concept. We are using a lot of our two-way video now. We project our image into a patient room so that they can see us. It’s like anything — when people are exposed to it and they get used to it, it can and I think will become more of the norm.

The only thing our ICU physicians can’t do from a remote location is, of course, lay their hands on the patient. What we’re finding is that certain procedures that used to be physician-only, now we are training advanced respiratory care practitioners to put in central lines and do certain things. There are only very few things that we would need a physician to physically do.

The technology has allowed us to have a conversation. You can physically see the physician. The video, the audio quality is great. We’re going to more and more probably see that as being the norm. Banner is expanding their telehealth programs to tele-psych, tele-wound care, behavioral health, tele-OB. You’ll probably see what Banner is doing with the telemedicine program on the horizon.

HIStalk Interviews Grahame Grieve, FHIR Architect and Interoperability Consultant

Grahame Grieve is a principal with Health Intersections of Melbourne, Australia and was the architect-developer of HL7’s Fast Healthcare Interoperability Resources (FHIR, pronounced “fire”) specification that allows EHRs to exchange information.

Tell me about yourself and what you do.

I qualified as a bench scientist in a hospital, but got dragged into working for a lab systems vendor. I got more and more involved in interoperability. Eventually I cut loose and consulted in interoperability and system integration in healthcare. Then I got gradually more and more involved in leading the standards in the area. Mainly I consult with the national programs.

Programmers call FHIR public API for EHRs. How would you define FHIR to a clinician and explain to them why it’s important?

It’s a framework for finding and exchanging data between two different systems so that they can exchange data in the background to provide services in the foreground that make people’s ability to do medicine better. You have to sort out flows, data contents, and agreements about responsibilities. FHIR focuses on doing those through modern technology, the same kind of agreements that support the massive systems around Facebook, Google, Apple, and the current social web system.

What lessons have we learned from the adoption of HL7?

It’s really hard to get people to agree. The content agreements and business agreements are valuable things that accrete very slowly. People line up with very long life cycles to them. You can’t expect quick change. You can legislate for it, you can pay for it, but you won’t get it. It takes time to get people to perform surgery on their systems while they’re going.

The criticism of HL7 is that vendors took advantage of its flexibility in making it less of a standard and more of a general framework. Is there a fine balance between being prescriptive enough versus making a standard too open?

Yes, it’s really difficult to find the right balance there. This variation in implementation was because vendors didn’t know any better and we didn’t have any way to encourage consistency of interpretation. We’ve tried to do what we can about that more recently.

There’s also variation because we have no authority to tell people to behave better, to act consistently, to make consistent decisions. Because we can’t dictate behavior, we have to tolerate a lot of inconsistency in the base specification. That fosters inconsistency in interpretation. It’s an ongoing process getting people to agree about those decisions.

What they don’t like is telling them how their business should work. But they do like to tell us that we should solve their business problems.

Are there concerns that the FHIR standard may fall short in meeting the lofty expectations that have been set for it?

There’s people out there who think that with FHIR we’ve solved all the problems. We haven’t, because we’re not authorized to solve lots of the problems.

What we’re trying to do is to get the interoperability format and framework out of the way of the problems that exist. They’re still real problems that will require real hard work to solve. I’m proud of what we’ve done with FHIR, but we only solve one of the set of problems that exist.

What else has to be done beyond developing and using FHIR?

There’s a set of things around security and understanding the balance between usefulness and risk in healthcare. Until we get a degree of agreement across a broad set of stakeholders about what risk is acceptable and what the trade-offs between risks and benefits are, that will continue to be a roadblock.

Then there’s a bunch of things needed around legal liability for exchange of data. There’s always ongoing tension about how much data people want to exchange. Exchanging data and commoditization are related. People will always resist commoditizing their core business. They’ll always be in favor of commoditizing their plumbing. Not a lot of awareness about the relationship between people’s interoperability and commoditization and plumbing in core business. Until core businesses align, then that will continue to be a challenge as well.

Finally, at the clinical level, there’s strong disagreements about clinical content and what kind of clinical statements you should be able to make and be able to exchange. Until the clinicians agree about what clinical interoperability is — not IT interoperability, but clinical interoperability, and that we actually need that — then the amount of clinical interoperability we have will be highly limited.

Was the past focus on document-based exchange a good learning experience and a good alternative or did it take us away from where we should have been going all along?

One of the things that I keep saying within the standards community is that you’ve got to accept your limitations. You can have what’s possible. We weren’t in a position to offer a data-centric standard. The industry went with a document-centric approach. It has great limitations around the ability to do workflow and data integration, but it has a great advantage around the ability to have some kind of immediate, computer-assisted data exchange for humans, where you have low agreement about workflow and clinical content.

Lots of the systems that have come to exist have come to exist because we did what you might call the low-coherency, document-based exchange approach. That’s continued to be a valid thing to do. We’ve gone out of her way to make that possible with FHIR while at the same time allowing people to cherry pick things and do data-based integration and exchange where the clinical processes support and need that. It’s going to continue to be a mixed picture.

When you look at the lack of interoperability, what do you think are the most important or the most difficult issues to address?

Moving data around costs money. Nobody really knows how much that should cost. There seems to be a strong view that the market value is not a fair value because the market is rigged. But none of the proposals that I’ve seen to fix that involve less rigging of the market. They’re just rigging it differently.

It’s extremely difficult to have any sense of what fair value for the cost of exchanging data is. It’s too easy to extract rent one way or another. That will continue to be a major obstacle because for most data exchanges I get involved with, there’s a real asymmetry between the cost of moving the data and the benefits of moving the data. The benefits typically accrue further downstream to someone who’s not paying for the data exchange and really thinks they shouldn’t need to. That will continue to be a big barrier to progress.

Other than that, getting clinical agreement about what the clinical interoperability needs to be and driving clinicians to change their practice to be consistent and to practice medicine consistently rather than inconsistently. That’s a huge cultural gulf that they’re going to have to confront soon.

How long will it be before patients can reasonably expect a new provider to have instant access to their existing data?

It’s a process. In the past, we didn’t have any way of exchanging data. We figured out how to exchange billing and identification data and some diagnostics. Then we added the ability to do some pretty crude document-based transfer of the data. That was a big achievement. I worked on that.

Now we’re extending that to cover through the JSON API task report to cover availability of limited data that can be looked at and maybe processed a little bit. A bunch of consortiums are working on getting better quality and more consistent data. That will take a lot longer.

You build a mountain, you stand on top of it and see a bigger mountain that you can go and stand on top of. The urgent need to build bigger mountains never goes away. We’ll just keep climbing up the stack towards a useful system. Each mountain is about a 10 to 15 year building process. That’s how it has gone historically.

Are we trying to do something in healthcare that other industries haven’t done in asking competitors to share their customer data with each other?

There’s a number of industries where they have data sharing arrangements of one kind or another. Those things are possible and they work to some degree. They need some kind of governmental interference or mandate to make them happen. Very often, most of those industries wouldn’t go back to the chaos they had before.

I live in a country where there’s not a lot of competition for business, but the interoperability picture is not very different. It’s really hard to move data. The US focus on competition and anti-competition is a bit overstated. Countries that don’t have a lot of competition still have trouble exchanging data unless they have a single provider providing all of the clinical systems. It’s just a matter of time to drive consistency.

One big problem people don’t talk about very much is legacy data. Almost all of us could easily get to an interoperable state if we simply one day turned off our legacy data and threw it away. Most practicing clinicians and clinical institutions are kind of reluctant to part with their legacy data. They call it ongoing care of a patient. As long as take that attitude — which we should — to healthcare interoperability, it’s got to be a slow process to move everything forward.

You mentioned that there’s a disconnect between who gets benefits from sharing data versus who pays for the cost of sharing data. What would be the ideal model? Should those who contribute data be rewarded in some way by those who receive it?

I don’t really know. Standards arise in a broken market. That’s a question that I’ve heard a lot of speculation about, but no convincing story. If the incentives were aligned, we wouldn’t need standards and people would just do it. We’re trying to move the market to a better, stable place.

Perhaps countries where they have a more holistic approach to funding … there’s a professor at my local university who says that we have an "ill-thcare" system rather than a “healthcare system.” If we focused on health and paid for health, then maybe the incentives would align differently. I don’t think that’s a very easy transformation to make.

What do you think of the work of the SMART group that uses FHIR as their data query method?

We love SMART. The SMART team are members of the FHIR team and vice versa. We have a very strong working relationship indeed. I think that 80 to 90 percent of the deployment of FHIR systems will also be a deployment of SMART on FHIR systems. It’s possible, although not certain, that SMART on FHIR will eventually become part of the FHIR specification. That’s water to go under the bridge yet. They’re doing great work. I really personally endorse their goals and they endorse our goals to the point where at some stage we might just be one team.

If you could wave your interoperability magic wand and have one wish granted, what would it be?

I wish the clinicians would believe in clinical interoperability the way that the IT people believe in IT interoperability. We’ve had doubters in the past, but pretty much everybody believes in it now if only we can get there. I wish the clinical people thought that that was a clinical problem.

HIStalk Interviews Adam Turinas, CEO, Practice Unite

Adam Turinas is CEO of Practice Unite of Newark, NJ.

Tell me about yourself and the company.

Three of us started the company. I have a background in digital communications, building various digital user experiences for a couple of decades. My partner Stu Hochron is a 30-year practicing physician. The third leg of the stool is Ed Guy, who’s a PhD in computer science and who has developed mobile applications and voice over IP and things like that for as long as these things have been in existence. That’s the three of us who created Practice Unite.

This is our fourth year in the market. We started as a specialized consulting organization focused on helping healthcare organizations improve communications because we think that it’s, if not the biggest, certainly one of the biggest problems in healthcare. Within a few months, we thought, wait a second, mobile applications can clearly help solve a lot of these problems. That inspired the idea for Practice Unite. That was about three years ago.

We’ve evolved Practice Unite to be a mobile enablement platform for healthcare. What that means is that we have a system for delivering configured mobile applications that help clinicians communicate more effectively, help improve the way that healthcare systems engage with the patient, and also help address communication workflows and things like the management of high-risk patients. Even solving some of the issues in home care.

We’re casting across all of the different domains in healthcare because there are some common communication problems. We’re able to do that because we have a system that allows us to create highly configured applications pretty much on the fly.

Who are your competitors and how do their products compare?

The core competitors are in the secure texting space — TigerText, Cortext, companies like that. Our differentiation is the ability to deliver a much more customized and configured solution. We can deliver a customized solution which includes an integrated on-call system with the ability to escalate integration with the EMR so that lab results and consults are delivered into different containers within the application. Then it gives the hospital system the ability to do things like target different types of content for different users.

For example, we can do things like deliver KPIs to an individual physician. If you think about secure texting as being the fundamental commodity — the foundation of this new generation of communications products — we’ve taken it to another level by using that as a foundation for creating different communications solutions.

The other element is that we bring in other modes of communication. We include voice communications, whether that’s simply using the phone’s dialer in a way that makes it easy for physicians to call each other or integrating voice over IP. We have our own client for that. We’re now rolling out secure video communications as well.

When you look across the market right now, the primary buyers for mobile communications solutions are the CIOs, the IT teams for the various healthcare organizations. They default to secure text, so there’s lots of RFPs out there for secure texting solutions. But as they get into it, they immediately see that there’s a lot more that we could be doing with this mobile application. If we’re going to go to the trouble of deploying a secure text solution, let’s address a range of use cases. It might be about improving different workflows. It might be about making it easier to find a physician on call. It might be escalation or delivering clinical data. The market has evolved from being a point solution for secure texting to becoming platforms for delivering all kinds of different solutions.

When we entered the market, there were a number of secure texting vendors who were out there doing very well with it. We thought, we’ve got to go a step beyond that. When we built Practice Unite, we built it with a view of, this is where the market is going to be in two years. We’re finding that that’s the case.

What are examples of clients using photos and video?

I’ll give you a simple text and voice example. One of the things that we’re doing is integrating hospital systems and phone systems into the solution. You have a nurse web-based desktop because nurses tend to want to put the application on their own devices, a whole other BYOD thing. The desktop is configured so that when they send a message out to a physician, it automatically puts their extension in. The nurse might send a message to Dr. Smith, “Please call me about patient Jenny Jones. I need to update you on her condition.” The doctor receives that text message and can click the message and automatically be routed through to that nurse. One of our hospitals actually went from doing 150 overhead pages a day down to three because the nurses don’t have to page anybody any more. That’s a simple use case.

There’s a video on our website — it’s a wonderful story. The very busy ENT surgeon at one of our customers is also chief medical officer. At the end of the day, a small child presents with an upper airway obstruction. He has the child admitted, runs some tests, and tells the hospital that he’ll come back in the morning and most likely operate, but he’s not really sure because he isn’t really sure what is going on with the child. By the time he gets home, he gets a critical lab result that shows that the child’s white count is highly elevated. He gets a radiology impression, which confirms that the child has a mass that is probably an abscess. He opens up the app, opens up the on-call system, finds the resident on call, texts and says, “Send me a screenshot of the the MRI.” The resident takes a screenshot of it, texts it to him, and he responds back saying, “Put the child in for the OR and I’ll operate in the morning.” He came in the next morning, operated, and the child was back in his bed by 7:30 and was discharged later that day.

What he said to us was, putting aside the economics of it, the child spends probably less than 24 hours in the hospital when he’d likely be spending 36 or 48 hours in the hospital. Putting that aside, it’s better for the patient. The parents of the child know what’s going on because he’s able to give them accurate information quickly. The surgeon’s life is a lot better because he knows what’s going on. A simple combination of different communications modes working together very quickly is what’s compressing the time.

We’re getting into some very interesting telemedicine pilots. I can’t go into the details, but we’re in conversation with a group that’s taking care of some very high-risk patients with a serious infectious disease. What they want is for the care manager to have the ability to do a secure video communication with the patient on a daily basis. You can do that with Skype, but because they’re doing it through a mobile app, you can then add other features into the mobile app.

For example, the patient can provide updates on their condition or they can send a text message to the care manager between the calls, because they’re probably only going to do a video call once a week. Between those calls, they can send a daily update on the condition. They can send a text message that says, “I’m really not feeling well today.” That way the care manager gets ongoing feedback from the patient on the condition and then once a week can do a video call with them.

What’s the future of secure messaging over the next five years?

Secure texting is becoming a basic fundamental part of everything. The notion of a standalone secure texting application will pretty much be obsolete within a couple of years. I can’t see a reason why people would just buy a secure texting application on its own. Secure texting will become an ingredient for a different solution.

Where I think the market is going for us and where I think we’re evolving to is the ability to be in the middle of mobile-enabling all of these different workflows and all of these different interactions between clinicians and each other and clinicians and their patients.

HIStalk Interviews David Lareau, CEO, Medicomp

David Lareau is CEO of Medicomp Systems of Chantilly, VA.

Tell me about yourself and the company.

I’ve been here since 1995. I discovered Peter Goltra and Medicomp when I was in the billing business and had a customer who wanted electronic health records.

We provide the MEDCIN engine and software. Our sole purpose in life is to present the relevant clinical content to a clinician at the point of care so that they can treat the patient, get their documentation, and have all the billing and Meaningful Use stuff happen in the background so they can focus on the patient, find the information they want quickly, treat the patient, and get on to the next patient. Not slow them down or get in their way.

You have quite a few physicians developing content and helping design the Quippe product and you’ve recently hired Jay Anders as chief medical officer. How do those physicians drive product direction?

We have a knowledge engineering team that, going back to our start in 1978, sits with the physicians and says, you’re treating somebody with asthma — what are you thinking about? What are the symptoms, history, physical exam? What are the tests and therapies? What are the other things that intersect with asthma? What are the co-morbidities? What would differentiate asthma from something else that has a similar presentation? It’s an endless series of peeling away the onion.

The questions that we have for the providers are, what would you want to see given this presentation? Some people think we’re trying to tell the docs, "Here’s what you should do." We’re presenting back through software what the doctors have told us they would want in that case. As you might imagine, it’s an iterative process. It never ends. Things are always changing.

We have anywhere from 15 to 20 physicians active at any point in time. They work with our knowledge engineering team. Jay Anders has joined us recently, because as you add more content to anything, it can tend to complicate life for the user. The more concepts you add to things like SNOMED, to other terminology sets — you’re seeing it with ICD-10 now — more content puts more pressure on the provider of software to make it usable at the point of care.

Jay Anders came on board because he represents the clinical end user for us. OK, Jay, I want your input on everything we do. Are we making it easier or are we making it harder? What should we be showing? What options do we need? How do we let the users control what they’re doing without slowing them down and getting in the way?

Putting more information in front of a user is not always the answer. It’s the right information at the right point in time. Does the engine have the content? Do the UI tools that we’ve built around it to help people deploy it provide for a proper presentation that the docs like, allow them to focus on the patient, and get all that other stuff in the background? There’s a lot more interaction.

One of the things Jay is doing for us is defining ways to do better work flows at the point of care and also recruiting our clinical advisory user  group of physicians, not just a knowledge engineering group. We have two teams that work in parallel.

How many employees does the company have and what do they do?

We have 20 employees now. The last time we talked, we probably had about 10 or 11. We have seven people who are developers. We have three people who do terminology, stuff like mapping to ICD-10, SNOMED, LOINC, Meaningful Use, etc. We have three people who do testing. We have three people in product management. We have three or four people in knowledge management.

Then we have the clinician advisors. We have two-full time physicians on board doing that. Then we have about 10 or 15 who are on staff at major medical centers. They’re not employees, they’re contractors. They do a lot of work with our knowledge engineers on the knowledge base using our knowledge editing tools.

Peter Goltra had a great idea in MEDCIN, but it didn’t feel like a real business early on. What does it take to turn a great idea into a great business?

Focus. Absolute core focus on what you do, what you do well. Any time you’re in the kind of business that we are in — development of intellectual property, development of content, development of techniques to present things — your sole asset is your people. You’ve got to find the best people and you’ve got to keep them.

I consider salaries the only expense I will never cut because those are the people who produce what we have that is of value. Everything else is negotiable. I can move into smaller office space. I can do less travel. I can have non-fancy furnishings, which we do. But we want the best people. We never want to lose anybody, because when you lose somebody, it slows you down. You lose their energy and other people have to make up for it. 

One of the things that happens in other companies is that they don’t focus on one thing. As they get successful, they start doing things they shouldn’t be doing. When bad times hit, they cut their head count. Our head count is our asset. That’s it. I’m not talking about in terms of numbers, I’m just talking about terms of quality. We pay people very well. We treat them very well. We contribute six percent to their 401(k) whether they do or not. We recognize them. We listen to them. We empower them. They love working here. We don’t lose people. That gives us continuity. That allows us to build in successive versions of what we do, on what we had before. 

We do not become unfocused by saying, “They said we should do dental software.” Somebody else says, “Why don’t you guys do a drug database? or somebody else says, “Why don’t you do this?” No. We provide an engine to present relevant information to clinicians at the point of care. That’s what we do. If it doesn’t have to do with that, I don’t want to do it. That’s it. Great software gets produced in small, very collaborative, highly productive teams of experienced people who know what they’re doing and are very committed to it.

I assume Medicomp has been around long enough that you don’t have impatient investors demanding that you do something that sacrifices long-term success for short-term profits. Do you see that happening with other companies?

Absolutely. Anybody that has to answer a quarterly conference call is under that pressure. Any time there’s a blip in earnings or revenue, they really can’t do long-term investment at the expense of short-term results, so they cut people.

We’ve seen some of our own licensees — I won’t mention any names, but the news shows up in HIStalk all the time — they cut and then they hire and then they cut and then they hire and they rearrange and they right size and they downsize and they expand and they cut. It’s a tough way to build a business.

Our advantage is that Peter got into this because he loves what he’s doing. He carried the company through from 1978 to about 1992. We are owned by employees, Peter, and some family members. Everybody here is a stockholder. We’re all invested in the same thing. We all have a long-term vision because we believe that eventually, these systems have to be usable by clinicians at the point of care, and right now, they’re not. That’s why we’re starting to make some inroads.

Are EHR vendors are concerned about usability issues given that most of their development agenda is sucked up by ICD-10, Meaningful Use, and quality measures?

They’re not concerned about it yet. There’s a couple of reasons. The government has just pumped $30 to 40 $billion into HIT. They said that in order to qualify for this money, these are the things you have to do. That’s been a great boon to the sales, revenue, stock price, and valuation of the big vendors because here it is — just do this and you’ll get it.

At the same time, ICD-10 CM is no picnic and neither is Meaningful Use. Those things are so challenging that many physicians have said, well, to heck with this — I’m going to sell out and become an employee. Then they become disempowered by the organization. It’s happened here in northern Virginia. There’s one health system that dominates. They’re buying up practices left and right. They don’t have to listen to the docs right now. They haven’t had to listen to them for a few years because they’re doing great. They’re addicted to this money, which has let them do what they do, not have to adjust, etc. The docs aren’t really empowered, so usability, schmoozeability, we don’t care. It’s not a factor yet.

We think it will be, which is why we have folks like Phoenix Children’s Hospital coming to us and saying, our vendor’s not delivering on usability. Our docs need something they can use. Can we give it a shot with your software and put it in? And they did. Their vendor, Allscripts, tried to talk them out of it, but ultimately cooperated with them. They put it in. Within nine months, their docs love it. They’re seeing 30 percent more patients per day and they’re leaving early. 

I believe that once the tsunami of money coming in dries up, they’re eventually going to have to turn back to, how do we make doctors more productive? Particularly given that with the new health insurance laws, there are more patients to treat and possibly fewer primary care docs to do it. As we go to outcomes-based reimbursement, they’re going to be paid for how well they care for patients. We still think that’s going to happen one patient, one clinician at a time. You need to be able to efficiently provide care, so at some point, you’ve got to make this usable by the providers. 

That’s what we’re hoping. We’re starting to see that. We’re starting to get some traction in that. And as you said, we’re a more patient company than most.

I thought your business was working through EHR vendors who signed up to embed your product into theirs, but Phoenix Children’s went their own direction. Will you offer Quippe or the MEDCIN engine directly to customers without their vendor’s involvement?

Well, possibly. I don’t want to do that. I want to go through the vendors. But Phoenix came to us. They asked their docs, “What do you want for documentation?“ They did about a six-month analysis with the docs. The docs found it. They presented it to Allscripts. Allscripts said we’re not going to do that yet — we might have something in two years. 

Then they came and played our Quipstar game at HIMSS and said, you guys have what we want — can we try it? We said no, we don’t do that. They said, we’re a co-development site for Allscripts. We have access to their code. We’ve convinced them to let us do it. They think we’re going to fail, but they said they’d let us do it.

They had a great team, which is why I don’t want to do it with many other people. They had the best team I’ve ever seen. There’s a reason they got that award a few years ago as the best IT department. David Higginson is a demanding visionary leader, I’d call him. He had one programmer work on this part time for about nine months. They did the full integration with SCM. It went very well, beyond their and our wildest dreams. We had to back up and say, hold on, what are we going to do now?

We’ve done a couple of things. We learned a lot in that process. We’ve made it much easier to integrate Quippe with an existing system. As evidence of that, the next thing we did was when Bangkok Hospital in Thailand came to us. They have an IT subsidiary called Greenline Synergy. We’re getting some really good traction in Asia, in the Asia Pacific region, but we’re not implementation and training people. That’s not what we are and that’s the danger for us. When I talk about focus, I don’t want to do that.

They came to me and said, we want to do a little pilot. We want to see how quickly we can take Quippe and stand it up in one of our ambulatory clinics, and if it goes well, we will consider becoming your implementation, training, support, and distribution partner in Southeast Asia. Because we already have Bumrungrad Hospital live on the nursing stuff and we’re getting a lot of traction in Malaysia, I said, OK, let’s try it. They came here on April 27.  They sent three people — two developers and their clinical lead. They spent two weeks with our team. They went back. They got back to Bangkok on May 15 and they are now live in their ENT clinics with Quippe for physician documentation.

Is the product the same no matter where it’s installed? There’s nothing that needs to be localized?

It needs to be localized. We’ve had to build in some options for people that allow for localization. We did a project about four or five years ago where we said, if they really want to present it in local language, we will never get caught up, because there are 300,000 concepts, positives and negatives for each, and multiple presentations of each. But we did a little study and found that about 10,000 meds and concepts constitute about 95 percent of all documentation activity. Common things are common.

We did that. We did a translation into Thai, Chinese, and Spanish just as a test. When it came back, people said, we don’t really care about that because we operate in English a lot, but we use different forms of things in English. In Australia, they say "nappies" instead of diapers. We had to build in some additional tools to say to people, you can replace things by user, by site, by specialty, by country, etc. It’s sort of a localization pack.

We also have made it much easier for people to change the way that the engine behaves, because infectious disease things in Singapore are taken much more seriously than they are here because of the density of the population — they don’t want hand, foot, and mouth disease getting loose in even one building because it’s so contagious, so they want the software and the engine to work a little bit differently. They want to promote those things and get them right in front of users. It’s similar to what happened here when everybody decided we had to ask a few questions about Ebola. Think about that as a massive localization at every hospital in the United States for a while, although it’s kind of died down now. We’ve had to put in tools that make it much easier to localize our content and localize the operation of the engine.

What will be the biggest factors impacting healthcare IT over the next five to 10 years?

The concrete is poured, in the United States at least, for people who have spent the time and money to put in the systems that they have, which are heavily based on transactions, billing, and organizing admission-discharge-transfer stuff. This is our hope and this is our plan — that attention will turn back to, what are we going to do? How are we going to make all of this big data that everybody’s talking about actionable at the point of care? 

People are going to take a couple of different approaches. People like IBM with Watson, people working on all the natural language processing stuff, big data, all that. They’re going to approach it from the standpoint of, we can analyze all this information on the population and we can detect trends. Now whether they can do just correlations or causation, I don’t know, but at some point, if you’re going to improve outcomes, that stuff has to come back and be usable at the point of care.

We think that’s our opportunity. That’s what we provide. If we’re wrong and nobody cares about that, I probably won’t be around for you to talk to me in 10 years. But we think it’s turning because we’re getting more and more people come to us and say, can we do what Phoenix Children’s did? We spent all this money, our doctors still can’t use this stuff, we’re not getting the data we need, and we’re not pushing it back to the point of care – please help us do that. I think after the dust settles with ICD-10 and Meaningful Use, the industry is going to turn back and say, we’ve poured the concrete, now how do we build a road that these docs and nurses can use?