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HIStalk Interviews Steve Brewer, CEO, Galen Healthcare

February 16, 2016 Interviews No Comments

Steve Brewer is CEO of Galen Healthcare Solutions of Grosse Pointe Farms, MI.

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Tell me about yourself and the company.

I’m CEO of Galen Healthcare, based in our Chicago office. Somehow I guess I’ve turned into one of the old timers in this industry now [laughs]. I was just looking at my schedule and can’t believe I’m about to head off to my 22nd straight HIMSS, which is truly unbelievable. That’s a lot of booth time, a lot of bad carpet.

Galen is essentially a consulting and technology services company. What makes us unique is combining incredible clinical and domain expertise with some of Galen’s proprietary technology platform and tool sets. It’s a combination of those two things, which are a unusual for a firm viewed as a consulting company.

We were just named "Best in KLAS" in both of our core categories. I just arrived here last fall, so I get no credit for that other than really good timing.

Are you seeing results from the KLAS awards or do you expect to?

We are. We’re seeing a lot of inbound activity.

Galen is pretty well known in our core markets. We’ve done hundreds of clinical conversions and EHR optimizations across a bunch of platforms, but we’re a smaller private company, so I wouldn’t say that we’re broadly known throughout the industry. It’s certainly great for name recognition. We’re excited about showing up at HIMSS to leverage some of that, to let people know more about Galen.

What issues keep you busiest these days?

The history of the company is interesting. It was started about 10 years ago by three gentlemen — who I knew back then — who left Allscripts to start a services business. They saw that no matter how good of a job Allscripts did on their side of implementation, most of the clients were going through it for the first time. They hadn’t been through it before and needed assistance. That was the early days of Galen, helping out at some of the largest early EHR implementations in the industry.

What we’re seeing now is a shift. People who have made these huge investments in clinical and financial systems want to leverage those. Our work has shifted a lot up towards conversions, archival, and technical integration of systems, connecting to HIEs and others. There’s been a lot of consolidation and M&A activity in the industry. Having all these systems truly interoperable and moving data in and out of them, or shifting people from one system to another, has become a big part of our work effort.

How are customers using your service that allows them to store and access information from their retired systems?

It’s one of our newer services. We’ve been doing conversions for quite a while and are probably the leader in that space. When one of our large clients acquires a practice or merges with another health system, we for years have done a lot of that  hardcore technical and clinical mapping of the data to get them converted. What we’ve added now, since we have all their data, is the ability to archive and retire those legacy systems.

It varies across the board which systems they are going to. We have been involved in numerous conversions to Epic and Cerner. We have a lot of large Allscripts clients who acquire practices and retire some of the older systems from the practices they’ve just bought. It’s across the board.

What are the most common systems you’re converting from and to?

The largest ones have clearly been to Epic. We’ve had some recent activity with regard to Cerner and Meditech. You’ll see a lot of the ambulatory systems that have been in the market who maybe get caught up in a large Epic conversion, even though they might be very happy with the system they have, and the ambulatory system is going to go away as part of that Epic conversion. Standards or not, that integration and conversion is a pretty significant effort that most of those groups haven’t been through.

Who do you admire in the industry?

I’ve seen a lot in those 22-plus years when I headed off to HIMSS in San Antonio in 1995, so it’s been a few different iterations of companies that have been success stories.

I was involved in a company here in Chicago, Enterprise Systems, that went public, got acquired, and then got acquired again my McKesson. That was interesting. I was there in the early days of Allscripts and the growth and the innovation of leading EHR adoption in the industry was very impressive. It would certainly be hard to ignore what Epic has done over the last five or 10 years, one of the probably great business success stories — even beyond healthcare — in the US over that time period.

How do you approach the HIMSS conference as a vendor?

I’ve always enjoyed it. To me, it’s a great event where a lot of people come out in the industry. It’s certainly a hectic four or five days, but I find it to be a lot of fun.

At Galen, it’s a little different. We’re a small private company. We’ve enjoyed nice steady growth, but world domination or some billion-dollar market cap hasn’t been the strategy. The strategy has been to build a great company and attract super smart people who enjoy being here and who are proud of the work they do for their clients.

From that standpoint, we’re going to be in a 20×30 booth. Hopefully people will know about us and come see us. We know our clients will. We’ll look to continue our reputation and steady growth. You won’t see us in one of those mammoth, block-long, multi-story booths at HIMSS. It’s a little different event for a company like ours, but still exciting.

What should HIMSS attendees ask consulting firms they’re talking to in the exhibit hall?

There’s a lot of different flavors of consulting companies out there. From our standpoint, it’s the combination of the technology we bring to the table as well as the people. A lot of the bigger companies focus on the staffing effort and the professional services, which we certainly do, but we are typically combining that with technical services, integration, and the like.

People should focus on, what’s your history? What do your clients think about you, and specifically, what are they trying to get done? I mentioned our niches earlier around EHR optimization, conversions, implementations, and a lot of the other tool sets we bring to the table.

You see massive efforts in this industry, billion-dollar investments to put these systems in place, and now with HIEs and the like. Where many people are falling down is on the integration piece, on that last mile of connectivity to the practices. Those are the areas we focus on. We coexist well with a lot of the other traditional consulting companies that are out there that typically don’t focus on that.

Population health and information security are hot topics. What are you doing in those areas?

As you’ll see at HIMSS, everybody in some way or another is positioning themselves as a pop health company, or patient engagement, or analytics. They all intersect. Galen’s role in that is making the data that those systems need accessible and relevant to do true pop health and to do true analytics across cohorts and population bases. That’s really what we do.

A lot of this data is stuck in EHRs. It’s stuck in other systems. We’ve worked with a lot of those HIEs and pop health products to get the data in and out so that those systems can do their work.

Security is certainly a big focus of ours as well. Anybody in this industry has to be focused on it. Galen might manage those overall projects, but I wouldn’t position us as a security consulting provider. There are some folks who specialize in that exactly.

You’ve won some awards for being a good place to work, which is probably tough as a consulting company where folks are remote or travel a lot. How do you manage the people side of it?

It’s probably tied to what I mentioned earlier, that the culture’s a little different and our end game is a little different, which makes it a great place to work. We don’t have outside investors. We’re just excited about having a really positive work environment where people learn new skills and enjoy what they do. That’s reflected in the rankings.

You’re right, it’s a heavy travel job and it’s a very intensive job for our consultants, so we very much appreciate their time away from families and the like. We try and balance that load to make sure it’s a sustainable job for them. A big part of what we do on the technical services side can be done from our offices rather than on site at clients, which helps.

Give me three bold predictions for the next five years.

I’m not sure how bold these are, but after years of talk, I think we are finally going to see some very rapid movement in a few areas. 

First, the new payer models will be here for real. That is going to increase the shift in patient services to new settings of care, such as retail, urgent care, and ASCs. This will also speed up the already active consolidation amongst health systems in the market. 

Another area I see acceleration is in the blurring of the lines between payer and provider as these organizations come together to manage risk and control cost. 

Additionally, we will see a shift to the next phase of connected care, where the EHR is no longer the center of the universe, but rather just one of many data collection and feedback tools that need to interact seamlessly with other surrounding systems. 

For Galen, I think these trends will match up well with our focus on optimization of current platforms while our clients also prepare for this changing environment. These new initiatives will require deep integration, conversion, and project management skills to keep pace with the market and patient needs. We’ll look back and see if I got any of this correct, but in any case, we will continue to adapt our business as the priorities of our clients evolve.

And if you’ll allow me to pick a fourth bold prediction, I’ll take the Bears to win the Super Bowl next year.

HIStalk Interviews Bob Gregg, CEO, ID Experts

February 15, 2016 Interviews No Comments

Bob Gregg is CEO of ID Experts of Portland, OR.

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Tell me about yourself and the company.

This is company number five for me in my career. Six if you count my early days as a CPA. Basically I’m a serial entrepreneur that loves to find companies like this that have huge market opportunities and grow them into significant companies that are making a difference.

I love ID Experts because we’re helping out not only the victims of data breaches that are at serious risk of identity theft, but also the companies themselves that are victims of data breaches of all kinds. We’re helping both sides of the equation. We’re helping the corporate entities that had the breach and we’re helping the individuals, whether it’s their patients, their customers, or who knows who they are. We take very good care of them.

How many breaches has the company managed and what findings have you observed from them?

I couldn’t count them. It’s measured in the upper hundreds at this point, possibly over a thousand. We’ve been doing this since 2006.

I guess the biggest change we’ve seen over the years is that a breach two or three years ago involved stolen laptops, thumb drives, those types of things. Now it’s much more serious. We’re seeing everything from organized crime to state-sponsored hacking with massive data breaches, particularly in the healthcare sector.

In the healthcare sector, one out of every two Americans has been breached in the last year and a half, which is pretty stunning. We just did not see breaches of this size and the number of breaches even two to three years ago. We didn’t see anything like it. Now we’re seeing these massive data breaches.

Unfortunately, in the healthcare arena, it’s pretty clear that healthcare is under attack right now from outside hackers.

What can hospitals do to make post-breach digital forensics easier?

The first thing I tell them is, don’t count on not having a breach. Just expect you’re going to have a breach in the near future. Get in place a master services agreement with somebody who is all prepared to take care of it. When you find the breach, you do not want to be scrambling, deciding who you’re going to hire, and how you’re going to approach it. You need to do all of that ahead of time.

Assuming you’ve done that, as soon as that breach information comes to your desk, you get hold of that group. They can get their forensics people in there quick as possible and they can get to that information. What you don’t want to do is over-notify or under-notify. You’ll want to get exactly who the victims of the breach are, then notify as quickly as possible once you have that information.

How hard is it to sift through the electronic trails to determine how many patients were affected?

Unfortunately, there’s no simple answer to that, because every single breach is a customized situation. I can’t think of any two breaches that are even almost comparable. It depends on the nature of their systems and how buttoned up they are.

Some breaches we can get in there pretty quickly, determine exactly which individuals were involved in the breach, and notify within a few days. Other ones are just very difficult because record-keeping isn’t quite what we would like it to be or the nature of the breach is such that there are multiple vectors of how the systems were penetrated. So, there’s no easy answer to that. Every one is in and of itself going to be different.

We have to be a little sympathetic to the provider when they have a breach. We don’t want to leap to our first conclusion. When we get the forensics people in there, we want to button up that process and know exactly who was breached before we notify. That can take some time in many cases.

What trends are you seeing in the technical nature of how breaches occur?

We do a survey every year for healthcare with the Ponemon Institute. We just last year published our fifth annual benchmark study on privacy and security of healthcare data. The big findings of that study were that, for the first time in the five years that we’ve done this, outside intrusion — criminal hacks — were the reason for the breach. That was never the case in prior years. It was lost data, lost hard drives. All kinds of inadvertent things that happened one way or the other.

Now we’re seeing absolute criminal attacks and hacking being the number one cause., which is a huge development. Because as we coach people, if you lose your laptop on a subway, chances of that laptop being used for nefarious purposes and going after the victim is, in our experience, really very small. If it’s criminally hacked with the purpose of getting that data, the chances that data is going to be used somehow in creating some kind of identity theft or fraud is pretty high. It’s a whole different situation when you get hacked.

What did you think when you heard about the hospital that lost access to its system for weeks due to a ransomware attack?

It’s an emerging threat, no question about it. We’re seeing more and more of it. We always counsel people to immediately get law enforcement involved. Don’t try to manage this yourself, for goodness sake. Get the professionals involved. Make a very thorough evaluation of the risk and the situation that you’re in.

Unfortunately, I have to predict that this isn’t an isolated incident or a few isolated incidents that we’ve seen here. We’re going to see more of these. Again, more and more reasons why you try to button up your systems. But as I said earlier, you have to assume that you’re going to get penetrated or hacked. Some kind of a breach is going to occur and you’d just better be prepared for it when it happens.

Should the average hospital or health system buy cyber insurance? How would that work for them?

I do, but with the caveat that if they do choose to buy insurance, get data breach professionals involved. Companies like ourselves, and there’s many others in the industry. Have one of them involved because every one of these insurance policies that I’ve seen are very custom with all kinds of sub-limits and exclusions.

You could very easily find yourself thinking you’re insured for a particular situation and finding out when you actually read the fine print that this policy excludes that type of situation. Unless you have a lot of experience in the data breach world in how these breaches can occur and what kind of exclusions the insurance companies will put into their policies, you could easily find yourself thinking you’re insured for something that happens, but you’re actually not.

Assuming you do that, I do highly recommend cyber security insurance. You will be hacked or you will lose data and it’s always nice to have some insurance to help pay for that.

Does cyber insurance cover the cost of remediating the breach? Does it cover lawsuits or fines?

There’s different types of policies. You can pretty much get your liability covered up to a certain limits. They’re all going to have limits. That’s classic insurance. It’s a tradeoff of how high you want to make the limits verse how much risk you want to take as an individual entity.

There’s policies available to cover the remediation of the breach, any loses occurred by the breach, even the lawsuit cost, which unfortunately too often happens as a result of these breaches, and the class action lawsuits. We have found that the actual cost of the lawsuits generally far outstrips the remediation, the notification, all those costs. You definitely want to be insured against the legal costs should those occur.

What trends are you seeing with health systems sharing threat information?

What we recommend to people is to watch what’s happening in the financial services world over the last five to 10 years. They follow the track of a lot of what we’re seeing right now in healthcare with criminal hacks and healthcare systems — the actual use of that data for identity theft and fraud and truly having identity victims from these.

These happened a lot in financial services five, six, seven years ago. They did just that. They started coming together and talking to each other. Sharing data on data breaches and the way people got in. They got law enforcement involved. They’ve done a reasonably good job of buttoning up their systems. 

Frankly and unfortunately in the healthcare community, the bad guys turned their guns away from financial services and towards healthcare, thinking they are a lot more vulnerable. They haven’t done all the things necessary to protect the data. It’s a lot easier to get data out of a healthcare provider than it is out of a bank or insurance company today. That’s the unfortunate fact. Our recommendation is pay attention to what financial services is doing and follow their lead.

What healthcare IT security issues will be important in the next handful of years?

It’s got to the board level now. We’ve had enough breaches and they’ve been high profile with enough victims involved that virtually every board of directors of a healthcare payer or provider, when they get together, they are now talking about cyber security and their breach risk. Just a few years ago, that was not the case.

The fact that it’s made it to the board room and people are paying attention … we’re seeing a lot more activity. Healthcare entities want to have that cyber security insurance. They want to a master services agreement with a data breach mediation company on the shelf and completely negotiated and worked out before the breach happens. A lot more systems protection. The CIOs and CISOs at these entities … their whole stature’s being raised up because of the risk that’s involved here. 

Good things are happening. Just like it happened in financial services, once the amount of the attacks and the fraud got to the point where it was intolerable, things started happening to fix it. They’ve come a long way. I think the same thing will happen in healthcare.

Unfortunately, I think it will take a number of years before it gets a whole lot better. In those interim years, we’re going to see a lot of data breaches. A lot more remediation that has to be done. I think we’re headed in the right direction. That’s the good news, but it’s going to take some time.

Do you have any final thoughts?

The whole reason ID Experts is in the data breach business is because we were founded on the premise that we want to fix identity theft victims from bad things happening to them. We have a 100 percent track record of doing that. Because of that, that just launched us into the data breach world and launched us into what we call the MyIDCare product, which is all of the things that we do to help people understand and remediate bad things from a victim’s standpoint.

One of reasons we chose healthcare as a primary market is that healthcare companies care about their customers and their patients. We see that every day. We get excited about that, because when a data breach happens, they step up. Unlike, unfortunately, the credit card companies and the banks sometimes. 

These guys really care about these customers and these patients. They want to do the right thing. We like that, because we obviously want to do the right thing for these individuals as well. We make a pretty good team going forward doing whatever it takes to recover these people from bad things happening as a result of the breach.

HIStalk Interviews John Marron, CEO, InMediata

February 10, 2016 Interviews No Comments

John Marron is president and CEO of InMediata of Charlotte, NC.

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Tell me about yourself and the company.

I’m president and CEO of InMediata. I’m a health IT veteran, for lack of better words. I have 20+ years of experience in what’s called provider connectivity, EDI, some of those similar terms.

I’m very fortunate to have worked both on the payer side — for a large, national healthcare company here on the East Coast — and on the provider side as well. I’ve worked for software and services vendors.

The company has two divisions. One is in Puerto Rico. I won’t talk much about that today, but InMediata’s division there that serves a little bit of everything — clearinghouse, practice management system, and EHR.

For the US business, we’re focused on payments and payment analytics. We’re positioning our company for today’s real-world problems of fee-for-service payments and helping providers who are moving claims and remits electronically who are having a terrible time reconciling payments, having a challenge on patient responsibility, and are trying to understand where their money is.

This is a new business. There’s nobody out there doing exactly what we’re doing. Lot of clearinghouses out there, a lot of practice management systems, probably a lot of EMR vendors. Most of them become partners for us. We think we are one of the innovative companies who are looking at the payment side of it and focusing on how to reconcile payments, remits, and deposits, which are the banking side of the business.

More than anything else, we’re trying to bridge the gap between healthcare payments from payers, healthcare payments from patients, and the banking side of it in bringing deposits to the equation.

Is it unusual for a revenue cycle management services firm to go all the way to the bank?

Most of them go almost all the way to the bank. Revenue cycle is a pretty broad term. Banking is, as the old expression says, the last mile of cable. They’ll deal with the deposit side of it solely. They’ll deal with the insurance company payment side of it solely. But there are not  many people bringing it all together.

You’ll see on our website that there are a lot of large provider groups. That’s our target audience here, groups who look at their back office process and find that they have accountants and CPAs going to banking portals and websites to try to help their organization reconcile where the money is at a certain point in time. I got a check, I got remit from a payer, I have to make sure that the money I was expecting is reconciled in the bank and I’m ready to run my business. 

A lot of companies are going around it, but not a lot are tying it all together. We think that innovation in integration is one of the key points for us.

How much inefficiency is left in provider’s revenue cycle management?

We think it’s largely automated on the front end. By that, I mean things like eligibility verification and claims submission. If you view that piece, and it’s an important part of the revenue cycle, it’s largely automated. A lot of the people who work with us at InMediata have spent their careers chasing that part of the business.

It’s largely manual and inefficient on the back end — payments, reconciliation, and payment analytics. Just truly understanding where the money is. We think there’s a lot of room left in that business.

How is the market changing with high-deductible insurance plans increasing the need to collect patient responsibility upfront?

We’ve heard about that coming for a lot of years. I would say we’re probably about three-fourths of the way down that path as well. More patients that are walking into the doctor’s office have some form of high-deductible plans. MGMA published really astounding numbers about how much money is left on the table if you don’t collect while the patient is in the office.

That tells a part of what we’re trying to to bring to the table. We are looking for reconciling payments from payers and some patients — anything the doctor’s office has to handle. We think those challenges are all workflow related. We’re trying to design our solutions around clicks matter, quick information, quick access to still-multiple disparate systems, and tying it to integration and workflow.

The challenge for a provider is knowing that a patient is likely coming in with a high-deductible plan, but not knowing much more about it. Trying to fit that into the workflow of seeing a patient, getting them through the healthcare system, and dealing with billing on the back end. It’s increasing, it’s problematic, and the things that solve it are workflow and integration.

What are the challenges involved with integrating those disparate systems?

They just don’t talk to each other. We’ve gone a long way of tying front-end processing standards. HIPAA did a great job bringing standards to the transactional flow. But when you get into the back office, you’re dealing with completely different systems that just don’t have the knowledge on how to talk to each other.

A lot of the payment people in the provider’s office are real good about accounts receivable, real good at managing what’s going on within the office. Of course, payers have their own adjudication systems — they can manage what’s going on in their own house. Banking has its own systems.

When that payment is made, that’s when they stop talking to each other. It sounds archaic, but we see situations where back office people are still going across multiple systems, entering data by hand manually in an attempt to reconcile an electronic payment, to an electronic remittance from a large insurance company, to maybe even an electronic payment from a patient site. That’s a lot of good digital information, but at that last end, that that last mile of cable, payment and banking are still not talking to each other.

Banks are heavy technology users. Have they made an effort to offer similar services from their end?

They have. Some banks, with what we’re doing, are becoming partners of ours. Our niche, something that we do really, really well, is that we think this business is about relationships and partners. A lot of what we’re trying to do it partner with the key companies that are involved. We know them. InMediata has had great relationships through the people that are here with us, with the practice management systems and billing companies within healthcare, and with the banks.

The challenge is the banks don’t always know the healthcare processing, and the healthcare software and vendors don’t always know the banking processing. That’s why I talked about that bridge earlier. Someone’s got to sit between the two and make that connection.

Banks are involved. They’re good partners with us. We can’t do anything without the transactions that are moving through the system. We think someone needs to be the conduit between the two and we think — it’s an old expression – that all healthcare is local. I’ll tell you, I’ve take it further and tell you that all healthcare is about relationships, and it’s about building trusted relationships.

That’s what our team brings. We understand the vendors involved in the healthcare side and now we’re getting an understanding of the banking transaction sets. We serve as that conduit between the two.

What business lessons did you learn in watching Gateway EDI sell itself to TriZetto, which was then acquired by Cognizant for $2.7 billion?

Culture matters. Gateway EDI is where I came from and is part of the equation. It was a company that talked every day about culture, about its people, about treating people well. An old expression says, “Happy employees will create happy customers and create a happy, healthy, and successful business.”

We’ve taken that to InMediata — that culture, believing in people, empowering your people, and creating accountability. Transparency of communication across your environment creates a really strong culture. We’re working on building that as well.

You heard me talk earlier about relationships. We think the culture of the employees that you have transcends to the customers that you’re serving and to the partners that you’re going to bring into the game. We think culture matters. We had a expression when I was there that says, “Culture eats strategy for breakfast, lunch, and dinner.” That’s what Gateway EDI was about. That’s what we helped merge into TriZetto. Of course, as you mentioned, Cognizant came in at the end.

We’re trying to rebuild that same culture at InMediata. We’re doing it people first. Happy employees making happy customers. We’re going to look for the same kind of partners, people that believe in employee-centric organizations, people that believe in innovation, and people that believe in satisfying and delighting the customer.

Where do you see the company in five years?

I’d like to be the Gateway EDI of healthcare payments and revenue cycle. We think we’re at the beginning of something that’s going to take us to an interesting place.

I’d like to see us helping move from fee-for-service to fee-for-value. We think that’s an obvious place the industry’s going. We’re trying to focus on what exists today and help us get to tomorrow. As payment models change, as quality initiatives continue to get pushed, as the payment landscape finally makes that change from fee-for-service to fee-for-value, we’d like to see InMediata right smack in the middle of all that.

For us, today’s challenges and opportunities exist around the fee-for-service model, around using those administrative transactions to help fuel the innovation for payment and payment reconciliation, and take that up to and past the fee-for-value model when quality really takes hold of the payment system and be there to help our customers get through what is, at this point, a rather intimidating change in the coming landscape.

Do you have any final thoughts?

We have a lot of experience in our company. If I had to give you an expression we use a lot, we’d say, "Words matter."

I was thinking about this interview and thinking to myself, "I want to make sure Tim knows about our company and about me and about our people." A series of words I jotted down on paper tells you about our company and our business. It’s people. It’s experience. It’s relationships. It’s innovation. It’s integration. It’s information. Just a set of words that I think are important. If  I had to describe ourselves in just a few key words, that would be them.

We hear about another word called commodity. The old EDI clearinghouse business you mentioned, Gateway EDI — people will talk about how that business has become commoditized. We view it completely differently. We view it as opportunity. We view it as value. We think there’s plenty of areas to help, plenty other places to go. 

InMediata thinks more about, why not? Why can’t we further that industry? Why can’t we find value where people see commodity? Why can’t we find opportunity vs. people see crisis? That all comes from a few words. People, experience, and relationships are key to the culture side, then innovation, integration, and information are the three I’s that we think are key to our business.

HIStalk Interviews Kevin Johnson, MD, Chief Informatics Officer, Vanderbilt University Medical Center

February 8, 2016 Interviews 3 Comments

Kevin Johnson, MD is chief informatics officer at Vanderbilt University Medical Center (TN), professor and chair of biomedical informatics and professor of pediatrics at Vanderbilt University, and a filmmaker.

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Why is VUMC moving from McKesson Horizon to Epic instead of to McKesson Paragon?

We have enjoyed a long history with Epic as one of their first revenue cycle clients dating back to 1995. We had made a decision to upgrade our revenue cycle and billing system to a more recent Epic version for inpatient and outpatient billing. We also have Cerner’s lab system.

Our decision, therefore, was to migrate our revenue cycle, clinical, and lab environment to Epic/Epic/Cerner or Epic/Cerner/Cerner. Paragon is a system constructed with a different size and complexity health system in mind. Both Cerner and Epic were good choices for us, and after a thorough evaluation, we chose Epic for our clinical system.

What is your Epic implementation timeline?

One of Epic’s strengths is that they provide a timeline and coaching to help our team configure, test, train, and go live. We are following that timeline with a plan to go live with Epic in a big bang fashion in November 2017.

We are fortunate to have a large and talented IT group, of whom about 50 percent are migrating to the Epic project. We think that their knowledge about Vanderbilt systems and infrastructure, coupled with their knowledge about our leadership and their relationships with customers, will help us deliver this system on time.

How will the Epic system help VUMC with its current and future patient care initiatives?

We have big plans for this. I will say right off the bat that Vanderbilt is a lot like other organizations that have constructed a leading IT infrastructure. We have areas with better adoption and areas that still have unmet needs. We have dependencies on individuals, rather than teams, that put some of our best innovations at risk. And we have workflow challenges related to the need to interface, rather than integrate, some of our system components.

Going live with Epic will usher in an era with a more unified patient bill, better access to mobile tools for patients and providers, and point-of-care access to reports and other aggregate data. Epic will be a high-reliability transaction processing and core clinical system for us.

Vanderbilt has always had a distinctive strategy for IT. We are retaining our vendor-neutral operational record, so that we will have three ways to potentially extend our infrastructure.

First, we plan to work with Epic to solve new problems and to innovate when possible. Second, we are capable of adding onto Epic through the use of SMART/FHIR apps and anticipate doing so. For example, to pilot student and trainee projects. Third, we will use our vendor-neutral record, if need be, to bring up specific complex functionality not yet supported by Epic.

Our plan, though, is to use this to free up our most talented developers to innovate on unsolved challenges rather than using their expertise to keep up with regulatory or reporting demands.

Is Vanderbilt still doing work to match genetic and EHR information?

Very much so. We are actively involved with the EMERGE (electronic medical records and genomics) Consortium, as are a number of academic centers around the country. Probably the biggest innovation we’ve been able to demonstrate is how to weave drug-genome interactions into the point of care through a project called PREDICT that was internally funded.

We were incredibly honored to host the second of the Precision Medicine Initiative workshops last spring and to push on the agenda of interoperability while also considering numerous approaches to abstracting EHR information for this program. Through the efforts of Josh Denny, MD, the PheWAS method, where we use NLP on clinical documents — in addition to using structured data in the EHR — to figure out phenotypes and then scan for variants associated these phenotypes we have convincingly demonstrated the power of combining genomic and EHR data.

The world of developing predictive models for disease is literally exploding, as we know, and will continue to evolve as new and more relevant data types, such as images and sensor data, are added to the analytic ecosystem.

What is VUMC doing with population health management?

Like almost everyone, we’re learning how best to do anything in population health management. I think the key point we all must address is how little technology really does to improve population health management. What technology does well, so far, is help with the aggregation and communication of data and knowledge around performance.

What we need to do is move from communication to active decision support at the point of care, better involvement of patients in their health management, and hardwired processes to act on information being distributed that requires manual interventions. The people and process parts of managing health are simply underappreciated.  

What we’re doing at this point is building that infrastructure, in addition to scaling work people have done with diseases like ventilator-associated pneumonia and asthma across the enterprise. We are excited about working with Epic users who have done a lot with that environment and population health, such as the work Geisinger has led for years. We have a few innovative ideas that may or may not pan out.  

I do have to share with you one story. When I got my Apple Watch, the first thing I imagined is how we could push reminders to clinical providers of care, using an in-room beacon to know which patient and which provider were engaged in the encounter. Very cool, until I first looked at my watch in front of a patient, who said, “I’ll only be a minute. Sorry to keep you.” The watch, unfortunately, has a lot of baggage we would have to overcome.

It’s clear that there are some great opportunities afforded by technology, but that in the era of widespread EHR adoption and dissatisfaction, we need to be very careful.

What innovative products or companies have you seen lately that excite you?

Other than my fascination with the Watch? Along the same vein, I have great expectations for the Amazon Echo. It just feels like the right interface to do what I described above  — real-time reminders and query/response decision support — in a way that could be easily integrated into the encounter.

I’m also very intrigued by work being done to demonstrate SMART and FHIR’s potential. There are a ton of startups creating wonderful apps and data visualizations. I hope we can harness some of this energy to impact the provider- and patient-facing health information technology systems.

Another thing that really excites and scares me is the phenomenon of big data. There’s a great little video from the ACLU called “Scary Pizza.” It shows one side of a very interesting issue, which is how simple systems can evolve using data from a number of sources. The goal of the ACLU piece is to scare us into fear about a loss of privacy. That’s one angle.

Another angle is to view it as an informatics challenge. How can we provide this level of decision support in a more acceptable fashion? For example, what if there was a way to use data about a house configuration to decide that the house might be difficult for rehab after a stroke? What if there was a way to know that the home’s electricity had been off on a few occasions, thereby changing the suitability for a home ventilator? I imagine that these types of data will truly transform the patient-provider interaction in the next decade.

What has been the response to your movie "No Matter Where?"

The movie tries to help lay audiences understand the issues surrounding information sharing. It’s been a very successful run so far. We had showings in Ann Arbor, Wisconsin, Tennessee, and San Francisco as a part of the AMIA meeting last fall. We have screenings being planned now in Indiana, Oregon, and Oklahoma. We have sold more than 100 copies of the DVD and are working on getting the film shown on public television. I’ve been pleased by the response so far.  We’ll see how 2016 treats us.

HIStalk Interviews Laurens van der Tang, CEO, VitalHealth Software

February 3, 2016 Interviews No Comments

Laurens van der Tang is CEO of VitalHealth Software of Minneapolis, MN.

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Tell me about yourself and the company.

VitalHealth was founded by Mayo Clinic and Noaber Foundation from the Netherlands. We deliver a cloud platform that efficiently captures patient-centered outcome data for quality improvement and cost reduction. We are healthy and growing, selling our solutions in the US, Europe, China, and India. Already more than 120,000 healthcare professionals use our software, and that number is growing rapidly.

I’m the CEO of the company and have been since the start.

Was intellectual property from Mayo Clinic licensed to VitalHealth? Do they have ongoing involvement with the product?

Mayo Clinic has been and still is very involved as launch customer and development partner. Mayo licensed intellectual property related to point-of-care decision support. The Mayo relationship means a lot to us. Our software is used by thousands of medical professionals at Mayo and we continue to jointly develop new innovative solutions that enhance patient care.

What is the product that you sell?

Our main focus is on patient engagement. We provide solutions for patient-reported outcome measurement – PROs– for instance using standard sets as developed by ICHOM, the International Consortium for Health Outcome Measurement. Customers include Boston Children’s, Duke Clinical, and AO Foundation.

Describe patient-reported outcomes, how they are collected, and how they are used.

As part of the move to value-based healthcare, it’s increasingly important for providers to measure quality of care, not just in clinical terms, but in terms that matter from a patient point of view. So, you get a hip replacement. Am I able to walk again? How long can I walk? Do I still experience pain?

What VitalHealth provides is the tooling that allows providers to engage with patients digitally in order to collect meaningful outcome data and to use patient-collected outcome data to improve the quality of the care. We provide seamless integration into the workflow of providers by connecting to different EMRs that are used.

Organizations learn and improve faster based on continuous specific feedback about outcomes coming directly from patients.

This is more than just measuring the patient’s perception of how well they were treated, correct?

Absolutely. This is based on validated standard sets developed by leading specialists from different countries. We are noticing increased adoption of PROMs around the world. It is a not only a great way to continuously improve quality of care, it also provides a way to make quality transparent for patients looking for the best provider to be treated by.

The main driver is the move to value-based healthcare in general. In addition we are seeing examples of payers mandating PROMs.

Do you have to sell the concept of patient-reported outcomes as well as your product, or have prospects already decided they want to move ahead with them?

There’s a little bit of both, but I would say that by now most providers have specialists that are very aware of organizations such as ICHOM and that are starting to take initiatives to implement PRO strategies within their organization.

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

I think we are seeing just the beginning. Today we collect data through questionnaires. Tomorrow we will add outcome measurements from many other sources, including wearables, sensors, and many other sources. We will do so real time and it will allow us to personalize care extremely effectively and efficiently.

Increasingly, treatment decisions will become shared decisions, with the physician and the patient being equal partners. Our goal is to be the global leader in this market.

HIStalk Interviews Marc Probst, VP/CIO, Intermountain Healthcare

February 1, 2016 Interviews No Comments

Marc Probst is VP/CIO at Intermountain Healthcare of Salt Lake City, UT.

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You have a history of speaking out about Meaningful Use. How has your opinion of it changed over the last several years?

Meaningful Use came out as a stimulus package. Did it stimulate the economy and health IT? It clearly did. If that was the plan, it was successful. Did it get more EHRs in physicians’ offices and in hospitals? It clearly did.

Did it move healthcare dramatically to lower costs, or even incrementally, to lower costs and higher quality? It has not. It has a long way to go, and because of the way we approached it, with check-the-box certification and achievement of Meaningful Use, it just didn’t deal with the underlying challenges of things like standards of interoperability.

The last point on that is simply how much money we’ve spent for the value that we’ve gotten. It’s minimal. All along, I felt we should have dealt with that and that’s why I’ve been so outspoken, a thorn, probably, in the side of my colleagues at ONC.

What was your reaction to Andy Slavitt’s remarks at the JP Morgan Health Care Conference, and then in the follow-up CMS blog?

On one hand, it’s disappointing because we’d like to see the end of Meaningful Use. I don’t speak for every CIO, but the ones I know were kind of excited to see it end. It wasn’t achieving necessarily all the objectives we want to achieve, so that was the negative.

The good side is that the national conversations picked up around what is the value of Meaningful Use and how the program should be changed to become more effective. I think that’s positive. The water under the bridge is how much money we’ve spent and the steps we’ve taken to this point.

The optimist in me things we’re going to have a good conversation about it. We’re going to talk a lot more about outcomes and how organizations can achieve outcomes that are better with technology. If properly done, properly incentivized by the government or not disincentivized by penalties, I think we can make some really important strides.

How would you like to see Meaningful Use transition into something truly beneficial?

I’d like to see it become outcomes-driven. If I can prove to you that I have lowered the incidence of diabetes or some of the clinical outcomes that are associated with diabetes because I’ve used information systems and data to do that, that’s a good thing. It lowers cost for the country and improves healthcare.

If we can do that with diabetes, let’s go to heart disease. Let’s go to incidence of jaundice in or around birth. There’s so many areas we could focus on, and if we turned it to that direction, you’re going to have clinicians and technologists working together to leverage these tools we’ve put in place to improve care and lower cost.

That ought to be our outcome, not whether or not we placed 60 or 90 percent of our orders through CPOE. If we can shift that conversation and then the incentives around that, I can just see massive innovation and much more benefit come out of these systems.

Intermountain is just over two years into its contract with Cerner. How is the partnership going?

It’s going very well. I think like every other organization, our very first go-live was a learning experience. Having to help physicians and other clinicians understand how to use the system was a tad painful. It wasn’t easy. We were Intermountain Healthcare. We thought we knew everything, but we had a few things we had to learn.

We did that last March. We went live with our first two facilities on clinical and rev cycle. That was two hospitals and about 20 clinics. Then we went live in late October with two more hospitals much larger in size, one of them our second-largest hospital.

Then probably 60 more clinics and rev cycle and everything surrounding it. That one went much better because we had learned so much from our first implementation and we’re now ready to go much more quickly. We’re going to probably bring up probably 12 to 15 more hospitals in 2016. We know how to do it better now, so I would say it’s going very well.

If you had to pinpoint one lesson learned that you’d like to share with other CIOs and IT teams, what would that be?

Adequate resources on the clinical side to help physicians adopt their work flows, without a doubt. It wasn’t technical issues. Technically, this thing went swimmingly. It’s all around adoption, use of the system, and changing work flows.

Did you bring in any consultants to help with those initial implementations?

The second one we did. The first one we did all on our own with Cerner’s help. The second one we brought in Leidos, primarily, to really help us get it done. They were very, very helpful. We’ll use them going forward.

What’s the biggest lesson you think your end users have learned or are in the process of learning?

Just how involved they have to be. You must have leadership on all levels. We’re divided into regions and then those regions have multiple facilities in them. That local leadership has to participate. This isn’t something that can be done to them. It has to be done with them. As they participate, our success rate goes way up.

What sort of ROI are you looking to get from your partnership with Cerner?

I don’t think any of us have fooled ourselves into thinking it’s going to be cheaper than our self-developed systems. What we’re getting with Cerner is a much more comprehensive solution. That’s been really positive.

Given that we’ve built systems very unique to the needs of Intermountain, our concern in transitioning to a system we didn’t build was, would we be able to retain that level of … I hate to use the word interoperability … tightness between what we’re doing from data analytics and what we’re trying to do from a process and workflow perspective to obtain those levels of best practice care and cost that Intermountain is known for. It’s actually what drove us to Cerner, because we thought we had a much better chance of doing it with them than we might with one of their competitors.

To date, that’s become much less of a concern. We’ve achieved a lot. We’ve done a lot of work in enhancing the core Cerner model system to have more of those capabilities, so I think our ROI is with this more comprehensive system and the greater amount of data that it provides.

We can go to the next level of best practice care. We don’t think we’ve gotten there. We think we can build in a lot more activity-based procedures and cost mechanisms so that we can even better understand where we’re spending money and where we can lower our costs and improve our quality. That’s really been our focus and that’s where we see the ROI.

The expense of doing something like this … did we lower IS costs or workforce costs? We haven’t really focused on that and we won’t. We know the benefit comes from providing better care and doing it at a cost that’s lower than what we’re doing today.

What is Intermountain looking to accomplish from a population health management standpoint this year?

We’re building a digital health strategy, and so this year we’ll be looking at how to engage patients with portals, mobile, that kind of thing. We’re really building out the strategy on how to do that. To suggest in 2016 we’ll accomplish a ton, I don’t think so. We’re just getting our ducks in a row this year as to how we’ll pull it off.

However, from the data side, we’re looking at understanding where our opportunities are around population health. How do we get to value-based payment and how do we contract with physicians that are going to be moving to population health and value-based care? We’re working with Cerner with HealtheIntent to support that exercise, but we’re also depending upon our legacy electronic data warehouse and traditional analytics.

What will you be looking at on the HIMSS show floor this year?

Security’s going to be a big issue. In fact, I just got out of a meeting to have this call, an all-day meeting that’s got some big players in town talking security.

Also, I think anything around population health and more visible things like portals, mobile, and wearables, that kind of thing. That’ll be pretty interesting to me.

Plus, I’m looking forward to connecting with old friends. I’ve been in the industry a long time and it’s a pretty small one, all things considered. It’s a great industry.

HIStalk Interviews Charles Tuchinda, MD, President, First Databank

January 27, 2016 Interviews 1 Comment

Charles Tuchinda, MD, MBA is president of First Databank of South San Francisco, CA.

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Tell me about yourself and the company.

I’m a physician technologist. I got a degree in biomedical engineering at Harvard, where I built prosthetics and a hovercraft. Then I went to med school at Hopkins. I ultimately got board certified and licensed in internal medicine. I got an MBA at Harvard Business School, working on venture and biotech.

I joined Eclipsys many years ago and worked there for quite a few years. Then I joined Hearst, first as their chief innovation officer for healthcare, and then ultimately had the great opportunity to lead FDB.

FDB is a company that I’m very proud of and feel very privileged to be a part of. It plays an important role in healthcare. Its roots started at UCSF around medication, but today we have immense impact. We’re touching multiple stakeholders across healthcare and have an opportunity to expand beyond that. That opportunity lives at the intersection of healthcare information and technology.

Because I feel like I’m a technologist at heart — in fact, I’m a closet programmer — I feel so fortunate to be at a company that’s passionate about making a difference, improving safety for patients but also trying to drive a bigger agenda around cost-effective care and value. The way that we do it is so interesting to me because we can leverage the electronification or digitization of healthcare, but leverage the workflows and the fact that it’s applied to technology to make it easy for patients and clinicians to do the right thing.

Physicians have often expressed their frustration at clinical decision or guidance alerts are intrusive and not necessarily relevant to the clinical situation that’s in front of them. Has that changed over the past few years?

It’s a very delicate balance to deploy very good clinical decision support. You’re aiming for providing people with information that they may not have routinely thought about on the possibility that you’d change their decision-making process for the better. 

When you look back at the history of decision support, folks may have started first in a world where there wasn’t any, so the first tendency would be to add as many alerts or as many informational prompts as you possibly can. People took a very comprehensive approach to that. If you review the medical literature today, people are measuring the performance of alerting systems by positive predictive value, trying to look at when alerts actually change behavior. You’ll see many research studies.

At FDB, we’ve taken a multi-pronged approach. One of the products that we launched in the last few years was AlertSpace. It has great success today. We took an approach that first allowed for customization of those alerts, tailoring the practice with the information that’s available. But we’ve also invested heavily in trying to increase the specificity of our learning engine, having to deal with many more patient inputs.

We in fact have a whole initiative that we call Advanced Clinicals, where we’re trying to replace the older infrastructure with a revolutionary approach to alerting. A lot of times, that actually means that the guidance is not given in the form of an alert at all — that it’s a framework. Maybe a series of questions. A process. You may get that guidance at different steps in the process. We’re on the road talking about it and we have clients that deploy it. We’re pretty excited about the potential there.

A lot of the clinical decision support setup is made by people who aren’t entering orders on the front lines. Would it be safe to allow individual practitioners to determine which alerts they want to see instead of mandating the same alerts for everyone?

That’s  a really great point that often comes up when we talk to clients. Institutions certainly have a view — often around the mindset of liability protection for the institution — where they want to roll out a certain set of alerts to prevent some of the most severe or tragic consequences. Clinicians, on the other hand, especially sub-specialists, deal with some very powerful medications and very tough and complicated diseases all the time, so that balance has been hard. 

That’s where  the customization play has worked really well. The difference is that I would say most of the vendors that we’ve spoken to generally don’t like to allow for individual personal customization, even though they technically can and have had that as an option. A lot of the institutions choose not to deploy it that way.

We’ve thought a bit about it. In the way that we’re rolling out our future solutions — especially those based on our cloud technology and our Web services technology — we’ve allowed for the possibility of us learning the behavior of that individual. Following them around the healthcare system and even seeing patterns in that data so that we can give them alerts that have been beneficial to other people like them.

Although that’s not quite deployed, we’ve laid a lot of that foundation to make that a possibility in the future. That’s like personalization around the information that individual clinicians would need to deliver even better care for patients.

Have we solved the problem of getting medications reconciled for a patient across their different providers and care settings?

No, I don’t think med rec is solved. If you look at the data of the penetration of med rec, obviously it’s now a requirement or a best practice for clinicians to med rec on every transition of care. When I talk to clinicians — including my wife — it takes an incredible amount of time and the workflow around it doesn’t make a lot of sense. 

That’s where we thought there was an opportunity. In our acquisition of a company that provided the MedsTracker platform, we saw a very innovative workflow with some really smart algorithms that made extremely great use of the information that we could provide. We’ve reduce the time it takes to do med rec dramatically. Cut it in half sometimes, down to 25 percent of what it used to be.

When I think about the future and the importance of med rec, it’s a really important decision-making process that’s going on when you’re choosing the drugs and how the patient should take those drugs. It’s an area where FDB will be able to bring more to bear in the future.

The traditional FDB work clinical process is around ordering and around dispensing the drug. Med rec is doing that in bulk, when you’re thinking about the disease and then going to go communicate that to the patient. For us to be able to leverage some really sophisticated CDS and then create the documents and artifacts that gives the patient the best education, the best understanding of what they should take — that’s the right thing to focus on.

Do you see the company’s role or product line changing as healthcare moves from management of episodes to management of care?

Yes,  I do. I hinted at a few things. Maybe I’ll make them explicit.

One is when I looked at FDB and first started thinking about the strategy, I thought FDB would need to able to touch patient data. Getting into the clinical workflow with this MedsTracker platform and being very comfortable — and frankly, HIPAA-compliant — I thought was going to be an asset for the company in the long run. I thought that the future of applying information would require personalization to the patient situation.

Then when I think forward about FDB’s agenda, we have a great heritage of providing solutions that improve the safety of medications, but I thought that the potential would be greater than that, to the extent that we would have access and the trust of patients and clinicians to look at their data and give them personalized guidance. I thought that there would be a big opportunity there.

We looked into clinical workflows, which is why obviously we had an interest in med rec. The future will allow FDB to demonstrate our ability to deliver more than just safety, that we would help people achieve the outcomes that they want and look at a wide range of inputs. Hopefully we continue to earn that right.

What challenges do you see for IBM’s Watson and genomics informatics companies that are trying to take theoretical knowledge from one system and insert it into the workflow of physicians using another system?

I love that people are investing in innovating in healthcare because I think it really pushes the envelope and gets people to think beyond what they normally might.

When I look at technologies like Watson, they inspire us to think about how we could leverage that type of approach to what we do. When I look at where it could be made helpful to patients and to our vendor clients, we focus around making it simple and embeddable. When you look at our MedsTracker platform, we’ve made it very simple to put in med rec. When we look at our Cloud Connector, why I’m so interested and excited about that is because we can deliver technologies like natural language processing, really complex risk algorithms, all through a Web service interface that would be very easy for a developer to pick up.

When you think about genomics, there’s a massive database behind that. Millions of mutations and millions of mutations of variants tied to drugs, drug-gene pairs, and those disease processes. That knowledge in the old scheme is really not feasible to deploy, because in the old scheme, you would ship the information out and hope that the EMR would build that algorithm and process it. You really need technologies like Cloud Connector, like a platform that makes it so easy for developers and consumers to use it.

When I look at these companies and these trends, I like it because I feel like it’s educating the market on what people should need to improve healthcare. Then I think FDB’s prospects are great because we’re very much dedicated to simplifying it and aggregating that information and making it easy to use and then focusing it right to a very specific workflow so people can benefit from it.

FDB doesn’t just produce clinical content, but also performs the subtle activity of integrating the information into standardized databases and working with EHR vendors to present it seamlessly to their users. Will IBM or other companies look to FDB as the company that can make their jobs easier by providing existing hooks into vendor software and databases?

Yes, absolutely. We have had conversations with IBM. We’ve had conversations with other large technology companies. In many cases, they’ve licensed our content to do precisely what you’re saying, meaning bridge the expertise gap that might be at their general purpose tech company with how it might be applied appropriately in healthcare, in the workflows. Genomics companies have also licensed and collaborated with us as well. In fact, we’re very excited about some of the things that we’re planning to show at HIMSS.

People would traditionally think of FDB as a medication information company. If you’re a technologist looking at FDB, you would realize that we’re a data aggregation and normalization company that brings complex information, simplifies it, and makes it very usable for technologists to consume and deploy. That’s why we have great channel relationships with all the major EMRs. It’s something that we continue to build on.

One thing that I tell my friends about my work that I really enjoy is the type of relationship that we have with many of our clients. We’ll walk into a meeting and we’ll have an opportunity to teach them about something. We’ll say, "Hey, guess what, here is the latest approach to drug interactions," or, "Here is the latest approach to genomics. You could offer it as a feature in your software product and you’re going to have great impact where everyone’s going to benefit from it."

We teach them technically how to pull it off. We give them the information that would drive that functionality. That’s the type of impact that we hope for and the fun that we have deploying the technology to make a difference.

Your cloud-based product could collect a lot of information about what’s going on in the customer’s setting, not just in the form of alerts that were presented, but also as a snapshot of patient information and situations. Could that information be useful to drug manufacturers or for safety purposes?

Absolutely. That’s partly why we started the investment and deployed our cloud product.

I’ll give you two examples. First, on AlertSpace. Over the years, we’ve built up a lot of feature functionality. From a features and solution suite, we have the industry’s best alert management platform. It’s extremely easy to use.

On top of that, we’ve added community and crowdsourcing capabilities. You can see what other healthcare institutions like you have set and their decision-making process around it. There’s a lot of additional content to bear that not only comes from us, but comes from the community.

When you look at our Cloud Connector platform, I’ve talked about giving folks access to massive online databases and sophisticated computational algorithms, but we have this hope that we need to validate, this belief that we would could probably offer a zero-install analytics and surveillance system. Something where because we’re running all the clinical screening CDS, folks can benefit from additional analytics and reporting about their high-cost drugs, about the disease processes that they’re managing, about which physician is seeing which patient. That’s something that we hope to introduce in the future.

When you look at our MedsTracker platform, it is a platform that has a lot of patient data in it. We’ve deployed a solution, such as clinical quality measures, which is quite innovative. It’s in the ordering process. The clinician is prompted to walk through whether they’ve fulfilled the clinical quality measure. The nice thing about that approach is that it’s proactive. If you forgot to give an aspirin, it will ask you, "Did you give the aspirin for this diagnosis, which qualifies for getting aspirin in the first 24 hours?" Then you can just order it alongside while checking off that you completed it.

That actually makes a difference. Most clinical quality and analytics systems are retroactive, so they’re just looking backward and seeing what people actually did. The approach that we’ve taken is on the front end. We think that has a bigger impact.

The other big area for us is around cost of therapy. When we look at cost of therapy and the analytics potential there, not only is it trying to understand the price, but understanding the outcome and the alternatives that you could potentially use to get the same outcome. That’s an area that we’re going to continue to investigate.

How do you see FDB’s role in looking at drug cost and how to evaluate which drugs are cost effective?

We continue to monitor pricing. We don’t publish AWP and we continue the decision not to publish AWP, but that doesn’t mean that we’re standing still. We’ve worked with various states and groups to develop a “better than AWP” benchmark. Although that hasn’t materialized, that’s something that we’re actively continuing to consider and push for on a variety of fronts.

That mostly then leaves us in the area of therapeutic alternatives. In the UK, we’ve deployed a wonderful product called OptimiseRX, which helps folks select the best drug. The best drug there is maybe more easily defined because of their NICE guidelines and their British National Formulary, but essentially it will offer appropriate drug alternatives that are less costly. There they’ve been able to show significant savings in the populations that they’ve impacted.

We think that here in the US, that’s possibly another option — offering therapeutic alternatives. When you look at the data about where the savings are coming from, it’s coming from a lot of interesting places, like dosage form changes. It may not just be an active ingredient change. We’re keeping track of where those savings opportunities might be and then trying to serve them up at the right time and make it simple.

How do you see First Databank and Hearst Corporation being involved in healthcare changes over the next five years?

Hearst is still very interested in healthcare. We continue to invest through the Hearst Health group in companies across healthcare. We’ve assembled a great family of companies that span the entire continuum of care. We continue to be focused on delivering care guidance. As an example, FDB obviously delivers medication guidance across the continuum, but you’ll also see our sister companies delivering appropriateness criteria, risk stratification, and other tools to help people manage and understand how care could be delivered better.

In the future, we’ll continue to expand and we’ll be hopefully an even bigger part of everyone’s life by focusing on integration, focusing on patients, and giving value to patients and the providers that take care of them.

Do you have any final thoughts?

FDB is in a unique position. We’re a company that’s extremely well trusted by the industry. It’s because we’re unbiased and we really try to do the right thing. We’ve done that for many years.

What’s so great about FDB is that we have the scale and the passion to invest, and I think that we in fact do out-invest in innovation compared to many of our competitors. Over the next few years, you’ll see FDB getting into new areas. Not only will be continue to upgrade and revolutionize our technology approach, we’ll be in areas beyond medications.

We recently launched initiative around medical devices. We’re exploring a few other areas that we think start adjacent to medication, so we’ll have the permission and the power to deliver value. 

My hope is that FDB will be the go-to company for folks to use and deploy whenever they think about making a difference in healthcare.

HIStalk Interviews William Winkenwerder, MD, Chairman, Winkenwerder Strategies

January 11, 2016 Interviews 2 Comments

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William Winkenwerder, MD, MBA is chairman and founder of Winkenwerder Strategies. He was formerly president and CEO of Highmark, Inc.; assistant secretary of defense for health affairs for the United States Department of Defense; and has held leadership positions with Blue Cross Blue Shield of Massachusetts, Emory University, Prudential Healthcare, Kaiser Permanente, and the Department of Health and Human Services. He serves on the boards of health IT vendors CitiusTech, Cureatr, and Accreon.

Tell me about yourself and what you do.

I am the chairman and founder of Winkenwerder Strategies. We’re a healthcare advisory and consulting firm. I focus my efforts currently — and our firm does — on innovative healthcare companies. In that vein, I work with a number of leading private equity firms who are investing in healthcare companies, serve on the boards of these portfolio companies, and invest in these companies. In addition to that, I have a group of advisory clients in the healthcare industry.

Prior to this, I served as the CEO of Highmark Health, one of the largest health insurers in the United States. I also served as assistant secretary of defense for health affairs with responsibility for all the healthcare for the US military and the Tricare program. My background prior to that was about 20 years in the healthcare industry working in the managed care sector, both on the health plan side and the provider side.

I’m an internist by background and training, board certified. I also have a business degree from the Wharton School.

What are the biggest challenges and opportunities in healthcare IT?

There are tremendous opportunities today in the area of health information technology. Healthcare continues to pose tremendous challenges for corporate budgets, personal budgets, and our federal budget, not to mention state budgets.

We continue to spend more money each year. We thought for three of four years that the healthcare cost growth might have been tamed, but it appears that it’s taking off again this year. We are spending now over $3 trillion a year on healthcare in the United States, representing about 17-18 percent of our entire economy. What is a really amazing fact is that over the next 10 years, we will spend many trillions of dollars on healthcare, and within 10 years, we’ll be spending over $5 trillion in a single year.

There are tremendous challenges with all of that cost growth to provide healthcare and pay for healthcare in more efficient ways. I firmly believe that health information technology as an enabler of better business solutions and better care processes is critical to that task.

Where do you think we’re spending too much and getting too little return in terms of overall population health?

We’re spending too much inside of institutions, principally in hospitals. The hospital sector is the most single expensive sector of the entire healthcare economy. More recently, we’ve been concerned about pharmaceuticals, especially because of price increases these last two or three years, but pharmaceuticals just represent 10 or 11 percent of the entire healthcare dollar. We’re spending a lot of money in the area of long-term care in caring for people with chronic conditions.

It’s difficult to put your finger on a single sector or single area within the entire healthcare economy that is responsible for most of the problem. It really cuts across all the sectors.

We can do things so much more efficiently. But in order to accomplish that task, there have to be the right financial incentives in place and the right information, not just for clinicians and administrators in the healthcare system, but also the right information for consumers to choose and make decisions about their healthcare in order to create more of an economy for healthcare services.

Until just the past few years, there has not been, in many areas, sufficient information for people to make decisions. There has not been sufficient engagement by consumers. That’s beginning to change. People are beginning to take healthcare decisions more into their own hands, principally because they are now experiencing some of the costs directly themselves through the changes in the benefit designs, which have more high deductibles and more co-insurance and cost sharing.

The individual and the family have a vested interest in getting value for their dollars. Even though that creates some pain right now, it’s a good thing in the sense that it’s going to force more economical provision of care.

You just called out the elephant in the room. Are people realizing that their despite non-profit status and source of community pride, hospitals are looking out for their own interests as they integrate to command more market power?

There are lots of shared and conflicting interests when it comes to the local community hospital or even the regional hospital system of today. The problem is that in many markets — in fact, probably most at this point — there is just one hospital system,  two, or potentially as many as three. This leaves in place a situation where there’s not sufficient competition. This is especially the case when the hospitals and doctors have come together in a community and really are just one force.

It reduces the number of choices that people have. Frankly, I think it creates a situation where there’s not sufficient room for innovation and change in the way that care can be provided. Being a physician, I think some of the most innovative models of care are through physicians driving change. I hope that, in the future, we’ve got physician-driven systems that are able to compete on equal footing with big hospital-based systems.

You worked in the Pittsburgh market, which was a bellwether for what was about to happen everywhere as providers became insurers, insurers became providers, and competition got ugly. You had UPMC as a national and even international brand. Will that also become common, where we’ll see the emergence of regional or national provider brands?

I do see the emergence of regional and national provider brands. To be clear, I don’t believe that this is all bad by any stretch. There are many great organizations that provide great care and that have developed a great brand because of their quality, their service, and their capability.

The problem comes when that entity acquires many of the resources, the assets for care within a given geographic region. Because healthcare is local, that creates a situation where there’s not choice, because people typically can’t drive hundreds of miles to receive services. It’s not like you can get your healthcare on Amazon or get the service delivered through UPS. You have to go to a local institution, a local doctor and so forth.

It’s important that regardless of who owns the assets, the rule book allows healthy competition to take place. In the absence of that, the only vehicle for control, if you will, of pricing is the government. The government typically has not been reluctant to step in to set prices or influence pricing where they can. I would expect that there will be a push to do that in other ways in other ways, pharmaceuticals, for example.

What has been the impact of the Affordable Care Act and what will it be going forward?

The Affordable Care Act has got, at best, a mixed set of results associated with it. On the positive side, we have more Americans who are insured, principally through the expansion of Medicaid, and to some extent, through the creation and operation of exchanges in most states.

The total number of additionally insured people, I think now is in the range of 16 to 18 million. Much of that is through Medicaid. I think the breakdown on that is like 10 to 12 million through Medicaid and six or seven million through exchanges. The target for the Affordable Care Act was in the range of 32 to 35 million. It’s fallen far short of the target. 

At the same time, it’s introduced a lot of requirements and burdens on employers that have not made a lot of employers happy. It’s also created a bureaucratic regulatory infrastructure that I worry introduces unnecessary costs as well as a potential for limiting innovation.

On the positive side, in addition to the newly covered lives, you do have some benefits from the introduction of products on these exchanges that take advantage of things like narrow networks or higher-deductible benefit plans that do, in fact, save costs. These, ironically, are the same things that many people complain about, but they are — from an insurance perspective — the best way to limit the cost to the individual. There’s really a Catch-22 going on with some of these developments.

Certainly this is a highly political issue. It’s been that for six years now, since 2010, and it’s going to be a factor in the 2016 elections. We’ll see where all of that goes. My expectation is that there will be a continuance of certain elements of the Affordable Care Act regardless of who becomes president, but there could be a lot of change to the Affordable Care Act depending upon who gets elected.

The middle class is being hit hardest financially with higher premiums, deductibles, and co-insurance because lower-income families receive federal insurance subsidies and high-income families can afford the higher costs. One ED visit could bankrupt the average family even with insurance. What do you think the average voter wants to happen?

You have to read lots of different polls and you get different answers. People seem to want, in my reading of all of this, coverage to be available that’s affordable, on the one hand. On the other hand, they like to have choice and they would like protection against some of these high costs of healthcare.

It’s really a double bind. There’s no way to provide a really highly affordable coverage plan, for example, in a market where there’s consolidation of providers and not much insurance competition. The cost of care is just going to be expensive.

My hope is that we set the conditions and the incentives into place such that cost of care can be driven down, not just held at bay or made to grow at a slower rate of increase. There’s evidence that care can be delivered at a lower cost than it is today, many times using good technology solutions and putting information into the hands of individuals and providers.

People talk a lot about patient engagement and consumer involvement.  Do consumers have more influence as customers and are providers recognizing that they must operate differently as a result?

I do believe that consumes are more engaged, have more influence on their care, and want more influence on their care. They are able to get their hands, if they’re reasonably educated and interested, on information about their particular condition. That’s available on the Internet. That’s available through information sources that people can easily access. People are driving decisions at a consumer level today in ways that just weren’t happening a decade ago.

People think insurance companies are the bad guys, but what are their challenges in trying to create and manage a risk pool?

This is where CitiusTech comes into the conversation. CitiusTech is a highly innovative health information technology company solely focused on healthcare and working across all sectors, providers, health plans, life sciences, pharmaceutical, and also working even with other technology companies.

What’s needed, as you try to develop new kinds of risk- and performance-based arrangements between the payers, between the health plans and the providers, and even the pharmaceutical companies, you need really good information. You need large databases. You need to be able to integrate the data. Ideally, you’re using the capabilities of the cloud. You’re delivering great information.

That’s what I found so attractive about CitiusTech that caused me to want to work with them. We started out our relationship about a year ago in an advisory capacity and then I was asked to join their board about six months ago. They’re a great example of a new kind of company that’s totally focused on healthcare and as deep knowledge of not just the bits and the bytes of the technology, but of clinical issues, clinical information, and clinical operations. When you take that and marry it to the financial side, the health plan world, you begin to create some tremendous capabilities and the kind of capabilities that people need today.

What kind of health IT companies would get you excited about either advising them or investing in them?

CitiusTech would be one for sure. I love what they do. I’m excited with what they’re doing. I think their focus is great. It’s not just the technology, it’s the services and solutions and great talented people. That’s one example.

Another great company that I’ve had a relationship with in the past, serving as a board director, is Athenahealth. Again, a cloud-based company that is on the leading edge of change in how they do things.

There are some newer companies that are focused in specific areas. Say, for example, companies like Vitalz and ZocDoc that are focused on things like the consumer and consumer choice. They’re companies that are focused on even things like personalized genetic information. That’s going to come into the lexicon and come into people’s consciousness in terms of things they want to know about themselves that may be predictive of their future healthcare issues and needs.

There are just a lot of great companies out there. Cerner is a great company, in my opinion. They just recently won the contract to create the next-generation electronic healthcare record system for the military, partnering, by the way, with Accenture and Leidos. I served as an advisor to them in their effort to win that contract, which they did.

There’s a long list. There’s just a lot of very interesting and exciting companies out there today. Obviously, if you go to HIMSS, you’ll get to see all of them and more. It’s an interesting time.

You led the Department of Defense in building their EHR that’s now being replaced. What was your reaction to its decision and the never-ending pressure on the DoD and VA to integrate their systems?

It needed to. The system that was implemented in 2003-2004 — that’s 12-13 years ago — was an earlier-generation system. It worked, but it was really clunky. It was not sufficiently meeting the needs of the Military Health System on a global basis.

It was a big step forward at the time. It was, at the time, the largest global electronic health record system in the world. People there can be proud of what was accomplished then, but rightly in my opinion, there was a focus on creating a next-generation system utilizing the resources of a world class consulting firm like Accenture along with Cerner and along with Leidos, which was formerly SAIC and had a lot of legacy relationships and had done legacy work for the Military Health System, and so knew and understood a lot of the ground-level issues. When you put those three entities together, I think you’ve got the best-of-breed total solution.

If you were king of healthcare for a day, what would you do to fix it?

Boy. It would take more than a day [laughs]. That’s my first response.

I think of the healthcare challenge in the United States on multiple levels. One is at a political level. The politics of healthcare have to be addressed and navigated. One is at a government level. We have existing government programs in place. They need reform, including Medicare and Medicaid. Then we have a private sector system that is connected to, partly governed by, and heavily influenced by government. They are moving parts and they’re connected. Any solution or set of solutions needs to take all of that into consideration.

At the end of the day, I think that what most needs to happen is policy change at the federal government level to set the Medicare and Medicaid programs on a course of financial sustainability. They’re not sustainable right now. There are policy changes that need to be undertaken, things like extending the age of eligibility to get into Medicare, other changes with Medicare and Medicaid, etc. I won’t go into all of them, but there are important policy changes that need to happen within those federal programs.

On the private side, we have to work to create a competitive system, as I’ve alluded to earlier, where there is competition between and among providers and providers and insurers. A system in which individuals can be engaged financially themselves, but at the same time, it’s a system that people of low income and little means have support and protection. When healthcare is costing $10,000 a year per person, or for a family, $18,000 or $20,000, somebody who makes $30,000 a year literally is not going to be able to afford healthcare. We need a support system for those individuals. We just must be very careful that we don’t create something that is not sustainable. Right now, we’re on a non-sustainable track.

The politics need to take ideas from both parties and it needs to be clear-eyed in its movement forward. One of the biggest faults of the Affordable Care Act is that it did not have a single vote from one member of a party that represents half of the people. It actually had votes against it from within the Democratic party. That’s not a good thing. When you want to make big changes, you really need some level of bipartisanship. I hope, as we look at 2016 and beyond, that there will be more of that mindset applied to try to solve those problems.

I’m ever the optimist. I like to believe that America is an innovative place and we want to do right by everybody, but we need to continue to develop solutions that can provide high-quality care to most or all of the people and do that at a reasonably affordable price. That’s the goal. I believe that health information technology is central to that objective.

HIStalk Interviews Gerry McCarthy, President, TransUnion Healthcare

December 14, 2015 Interviews 1 Comment

Gerry McCarthy is president of TransUnion Healthcare of Chicago, IL.

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I’ve been in healthcare IT since 1991. I landed a job at HBOC right out of college, working as an installer on the Star system. HBO was eventually acquired by McKesson, where I spent the majority of my career with roles in services, sales, product management, and operations.

I left twice in the 1990s to join startup organizations, Automated Healthcare and Abaton, both of which were sold back to McKesson. McKesson has been very good to me and my family over the years. After I left McKesson, I was the chief strategy officer for HealthMEDX, a long-term, post-acute care EMR vendor. I then joined TransUnion two years ago as the president of healthcare.

Most people know TransUnion as a credit bureau, but that’s really only one aspect of the company. We have three key divisions representing consumer, financial services, and healthcare. In healthcare, TransUnion focuses on the patient access and reimbursement area of revenue cycle management. Our main solutions are eligibility, ID, propensity to pay, charity care determination, payment plan recommendation, and insurance coverage discovery.

What kind of financial pressure are consumers feeling as the health insurance model changes?

From the Affordable Care Act, there’s been a lot of unintended consequences associated with underinsured. Now that more people have access — which is a great thing — we’re starting to see that people are struggling with being able to pay their bills and understanding what they need to pay and when. From a consumerism perspective, people struggle with how they make clinical and financial decisions based on the care that needs to be provided.

Medical bankruptcy makes up a significant percentage of personal bankruptcies. How do you see that changing over the next few years?

We see it increasing, back to that under-insured component. People think about the indigent and lower income. If you look at even the Baby Boomer generation, there was this perception that Medicare is free. All of these plans, whether it’s Medicare or these high-deductible insurance plans, are causing a significant churn within the marketplace.

Because we are TransUnion, we understand the credit bureaus. For example, the average household income is roughly $60,000. Some of these high-deductible plans are reaching $5,000 for a family. If something happens in January or February, people are immediately under water from a payment perspective against their current income.

This has been a struggle for people. We’re going to continue to see a rise in medical bankruptcy.

Not only are networks getting narrower, but some insurers have quietly eliminated out-of-network coverage completely. What will the impact be?

We see more and more movement towards consumerism in healthcare in general. It has a significant impact on our business and is an opportunity. If you look at what patients are demanding, they’re demanding not only the access to care, but they want to know what it’s going to cost before services are rendered. 

Whether it’s value-based care, where there’s potentially a flat rate on a risk-based model, more and more organizations are saying, "There has to be some level of estimation and transparency up front so the patients are educated." That’s a key component of what we do.

If you look at the transparency component, what we’re seeing more and more is it’s not just the hospitals providing this information. You’re starting to see payers provide the information with both clinical and financial data to their membership so they can make the best clinical decision with the best financial outcome based on their individual plan. That’s really the goal — to get that transparency in front of the patient so they can make those decisions.

You can ask someone at the point of service what you owe and they can’t tell you – they don’t know how the encounter will be coded and everybody pays a different price based on the insurance contract. How can that transparency logjam be broken?

You’ve hit the nail on the head. You have to be able to model the actual plan information and the contract that will impact that individual. It costs more money and it’s more time-consuming to implement and do those types of solutions and services, but that’s the first piece.

The second piece is that as the patient enters the system, things change. It’s not always straightforward that this is the DRG from start to finish and this is how we’re going to code that claim. There has to be financial counseling throughout. You have to make sure that you are being transparent with that patient. As they are going through the system and the solution, financial counseling is becoming a key component of what’s happening in the care delivery model during the care as well.

Both sides want something new to happen at the point of care. The patient wants to know what they owe and the provider wants to be paid before the patient leaves. Can those interests be reconciled?

I don’t think it’s ever going to be 100 percent accurate just because of the nature of how healthcare is delivered, but based on certain procedures or certain disease states, we can get much closer. When you think about heart and ortho and standard visits are happening within the physician practice, there’s no reason why we can’t get to that level up front, where everybody can understand and ensure that you have the right patient, we’ve checked for fraud, ID, we understand the credit history of that patient, the clinical history of that patient, and we can put forth a payment plan recommendation so everybody understands that entire process all the way through.

It’s not just an eligibility check any more. It’s the ability to take all of those things into account and then also look for 501(r) charity determination. These are things that our customers in the marketplaces are talking about right now.

It’s less likely that the patient will pay once they’ve left the provider’s premises. What are providers doing to increase point-of-service collections as patient responsibility increases while also knowing that people don’t make paying medical bills a priority?

That’s key right there, to make sure that up front you’re actually providing some level of cost estimation so they clearly understand exactly what is going to happen, the care that’s going to be provided, and the potential cost associated with it.

Studies show that the patient is seven times more likely to pay the total bill on time if you receive at least $1 at the point of patient access. That whole entire step of financial counseling up front with that transparency and estimation is what drives the patient behavior.

So if a patient pays anything at all up front, they feel engaged enough to be more likely to pay the remainder?

That’s correct.

You also make a very good point that patients look at healthcare bills differently than they do everything else in their lives. Being TransUnion with our financial background and history as a company, it’s interesting to see how people pay mortgage versus cell phone versus any other prioritized account. The number one reason of whether or not people will pay their healthcare bill is if they’ve paid a bill in the past.

In the ranking of what a consumer actually will pay for, surprisingly, the cell phone ranks higher than the mortgage.

Will consumer satisfaction with providers decrease as their insurance pays less for services, leaving the patient to personally pay the provider more?

Yes. We’re starting to see for the first time within our customer base and within the market that patients are starting to shop. That does influence. They will leave a provider and go to a new provider if they’re not offering tools. For example, the ability to pay online.

The point that you’re hitting on is very valid. Patients who are dissatisfied because they’re receiving a bill that they didn’t expect to get are more likely to search out a new provider in the future for medical care.

A broader concern for me is those patients who are looking at that bill and then putting off care. It’s not even the fact that they go search for another provider. They feel that they can’t afford it, which leads us to a longer-term problem that it will be more expensive to treat that patient down the road, especially if they have some level of chronic illness.

Are some of your revenue cycle customers finding the process changing so much that they will consider selling out or, in the case of small practices, closing?

What we’re seeing right now is a trend that’s growing substantially at a 20 percent CAGR is the outsourcing of revenue cycle management services, both in physician practices as well as in the hospital setting. Many organizations are stepping back and saying, is this really core to our mission and who we are, which is truly providing the best care for the community and the health of that community? Many organizations are looking to vendors like TransUnion and others, partners of ours like Conifer and MedeAnalytics, that are growing their customer base by outsourcing their core competency of revenue cycle management.

Thinking back to the case of Accretive Health, do outsourced revenue cycle vendors have to be careful to avoid embarrassing their provider customers by using overly aggressive collections practices even as collecting the money owed becomes harder?

It is a fine line for hospitals to turn around and walk when it comes to collections. That’s why it really begins on the front end of patient access.

There’s two things that hospitals can be doing. Number one, working with your collections team at the patient access level up front and using transparency to make sure that the patient understands fully what the costs are and beginning that financial charity and propensity to pay education immediately. That’s the first step.

The second step is, before it even goes to some level of collections, we’re seeing more and more organizations … if you look at uncompensated care, one of the key components of uncompensated care is that almost 5 percent of accounts that go to bad debt have some level of insurance that neither the hospital nor the patient is aware of. Our eScan solution goes and finds all of that data and information and allows hospitals to bill that back. I was just at a hospital last week where a CFO thanked us for finding $4 million in billable claims that they were going to write off to a collection agency to go find. Our goal is to make sure that that happens before it ever becomes a collection issue where you have to involve the patient.

Will a lot of hospitals run afoul of the 501(r) charity regulations that will become a condition of their non-profit status?

We just did a seminar that you helped us put on last week. We had over 250 organizations represented on that webinar. We’ve been surprised at how much hospitals have embraced and wanted to be educated on 501(r).

We do believe that they’re extremely nervous about their tax-exempt status and making sure that they’re following up on everything to follow that law to keep that tax exempt. There’s been a couple of cases recently where hospitals had to write large checks back to counties or states or even the federal government. 501(r) is here to stay and we believe hospitals are paying attention to it.

The company offers data breach-related services. What trends are you seeing?

You can’t have a conversation with anyone in healthcare today without talking about data breach services. First and foremost, we get the first phone call when it’s almost too late, when people are calling and saying that we need to provide credit protection services that TransUnion offers to the affected population. It’s more important, obviously, to have those controls up front to manage that data and lock that down.

You’re seeing a significant spend that’s happening within healthcare being shifted away from EMR and even revenue cycle opportunities as people are investing in their data centers and their policies and controls to make sure that you do not lose access to that data.

Is is sustainable to use HIPAA to fine breached providers even when they followed reasonable standards and the type of breach they experienced could have happened to anyone?

HIPAA is actually a very solid approach, we believe, to make sure that you can maintain patients’ data rights and integrity of that information that we’re supposed to be great stewards of. When you look at, though, some of the impact of HIPAA, this information of going to — whether it’s quality indicators from a clinical perspective or getting after the right financial information — some of these are onerous and put us in a position where we know we could solve some of the problems within healthcare, but some of the regulatory components are actually holding us back from being able to do it because we can’t share and utilize the data in the way we want.

I think finding the right balance between how we manage and maintain that data for information for good versus some of the bad things that are happening out there from the hacker perspective needs to be taken into account.

How do you see the short-term future playing out?

Consumerism is going to continue to grow and influence how care is delivered and paid for. Consumers really must go through the exchanges. They’re struggling with the decision on which plan to choose with little insight as to what the plan will cost them in reality. This is similar to how hospitals are making decisions on risk-based contracting models. They’re shifting that all the way down to the patients. Payers and providers are pushing that cost out.

Patients struggle with the high-deductible plans. The reality that Medicare and ACA aren’t free is setting in. More and more we’re going to start seeing the consumerism play, where patients will want to be educated on outcomes both clinical and financial. When you look at these new “payviders,’’ when you look at health systems that are offering insurance plans, and you look at the large commercial payers, everyone’s trying to get back directly to the patient.

I think there’s going to be a huge shift towards consumerism, where we start providing more and more data and information to them from a clinical and financial perspective so they can make the decisions. Because they are the persons who are ultimately going to be responsible for their healthcare spend.

Do you have any final thoughts?

I’m very thankful for the opportunity to be with TransUnion Healthcare with its great employees and focus. We have very quietly become a leader in the RCM space. We look forward to seeing how this continues to unfold and how we can support it.

HIStalk Interviews Kim Sell, President, Clinical Computer Systems, Inc.

December 7, 2015 Interviews No Comments

Kim Sell is president of Clinical Computer Systems, Inc. of Elgin, IL.

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Tell me about yourself and the company.

I started working in healthcare in 1992 for our predecessor company, Peritronics. I left that company in 1997 and started a service company, Clinical Computer Systems. In 2001, we acquired Peritronics and have grown it since then. Today we are a 100 percent employee-owned company that is focused on OB data systems. We have about 100 employees and plan to grow that another 10 percent this year.

How does an employee-owned company work and how does that impact the company’s philosophy and strategy?

We can focus on the things that we think are important to our company culture, to our customers, and to our employees. We don’t have outside shareholders or an exit strategy that we have to worry about with a three- to five-year horizon. We can do what we feel is right for customers and employees at different times without the constraints of outside capital. I don’t think outside capital is wrong — we have evaluated outside capital at different times for ourselves — it just has to be done at the right time for the right reasons.

Obix is FDA approved as a medical device. How does that change how your developers work?

I don’t know that it’s a massive change, but it definitely does introduce a different level of internal review and consideration of what we’re doing for the patient, for the customer. It also helps to define the market a little bit more, where it is a market that has some risk that sometimes a larger company or a different type of company wouldn’t want to enter this space. There are some differences that it does create and it’s risk. You have a government entity that could basically walk in at their choosing and shut down or challenge the company’s premise at any time.

I think we have a more stringent review process and a more stringent testing process that goes out. Also, it gives our customers another voice. If they’re not happy with how we perform, we also have to be aware that there’s a government regulatory body that they can go to to complain about us, challenge how we do things and how we’re satisfying them. Risk review and risk evaluation.

What are the clinical and legal issues faced by your perinatal technology users that are different from the rest of the hospital?

It’s one of the few, if not the only, area of healthcare where it’s really not an illness. Having a baby, having a pregnancy in and of itself is not something that is not a defined illness. A patient goes into a hospital in that condition and exits usually even happier.

The risks that go with that, though, are that it’s also one of the most litigious or most expensive areas of the hospital. The last stat I I saw behind anesthesiology is that it’s the most litigious part of the hospital in terms of settlements and risk management. It’s an area where they have to make sure they’re covering their bases and making sure that they’re doing the right things not to create exposure for the hospital. We help with that, making sure the care protocols are right, that they’re following the right care paths, and are evaluating the patients appropriately.

Do most L&D areas use software to assist them in the perinatal process or do some still use paper?

It’s a replacement market for us. I would say probably ninety percent of hospitals that have a labor and delivery department have a central monitoring system. We maybe run into one or two a year that do not.

Where does Obix go from here?

Our history has been focusing on services and integration with enterprises. The last few years with ACA and Meaningful Use, we’ve been focusing on trying to create a product that’s fully integrated, where you almost can’t tell the difference between our product and what is … everybody’s driving towards a single source of truth type of product and trying to support that strategy and make that useful for the users.

The enterprise products, many times, aren’t developed for the work flows and some of the unique situations for certain critical care areas of the hospital, L&D being one of those. We try to tailor our product to help support the user, support that big investment that the hospital has made in the EMR.

How do you convince a hospital that it’s a good idea to go with Obix rather than a product from their EHR vendor?

Other than Cerner, the other primary vendors really don’t have an OB product. Our competition at that level isn’t the EMR, but other perinatal specialty companies or companies that have perinatal products.

We work at messaging what the strength of our product is in terms of uptime and in terms of service and support. Service and services are a big part of what the company was founded on, has evolved with, and will always work to stay with in the future to make sure that it’s not just about dropping a product in place and saying, “There you have it” and walking away, or, “Issue a purchase order for more services.” We have a very integrated solution where it’s purchase the product, issue a support agreement, and we provide all the services around that. That’s really all a hospital has to provide.

Who makes the decision to buy your product?

That’s a trend that has changed a lot over the time I’ve been in the industry. When I first started, it was a lot of the doctors. Then it went to the nurses, nursing staff, went to IT. Now, honestly, we’re mostly in administrative decisions because of the purchasing cycles that things are bought in. We are starting to see physicians to have a larger voice again, but that’s a more recent trend.

You mentioned malpractice. Do you have plans to integrate a video record of what happens in the delivery room?

Not for us. I would suggest that’s another specialty area. When you get into recording the actions of what happens in the room, there’s a whole different set of issues that a hospital’s concerned about that I think are best dealt with a different specialty company and product if that’s a direction a hospital would decide to go into.

Is remote access important?

Oh, very important. I don’t know that we even think about it as remote access any more. It’s just access to information. The access to the information has to be the same in the patient room as it is for a doctor that’s at home at three o’clock in the morning trying to access the information.

Our biggest challenge around that is keeping customers up to date with our most current releases that have the better functionality around that. We have a number of customers that implemented software 10 years ago and really struggle to encourage them to keep upgrading the software and keep it current.

Obix has won the KLAS rankings quite a few times in a row. How do you use the feedback from users that KLAS provides?

It’s a big part of the sales process. It’s a big part of our business process, though, too.

We take a look at the KLAS comments. It’s not just the comments about us., it’s the comments of our competitors. We try to learn from everybody ourselves and our competitors and see what the industry is saying because it is a good way to get an unvarnished set of information and feedback from customers. To pay a market research group to do your own research sometimes gets some biases involved with it, where you’re looking for some specific things. I don’t always agree with some of the things that KLAS comes out with, but it does give us some good feedback to change how we operate as a business and to try to provide the services and functions that our customers are looking for.

Where do you take the company from here? Do you just keep working to gain market share or start thinking about developing other products?

We’ve considered a number of different avenues down that path. We have decided to stick with being a niche vendor in the obstetrical space. We are looking at other products and functions down this line, but I don’t see us growing out and trying to become another multi-disciplinary, multi-area vendor. I think it’s important for us to try to hold on to our specialty and focus on creating a best product and best services in that area.

Do you have any final thoughts?

I’m very thankful for the people that we have in the company. Of all the things that we deal with — with people, industry, and customers — finding and recruiting good and talented people within the company is one of the most challenging things we do. We work at improving that every day.

I see a lot of challenges coming forth, though, for our hospitals and healthcare organizations that we support. You’re seeing consolidation or trading of organizations in enterprises to consolidate market share. That’s going to create some new and different challenges both for the hospitals and the vendors that support them. Some of it’s good, some of it’s bad in terms of what that concentration does to different companies. We are making changes in our organization to support that. We’re trying to make our product lighter, faster, and easier to implement.

We just brought a new feature online called Obix University, which is an LMS platform that allows us to change our education process to be a continuous education process that’s online all the time, or it will be shortly. It’s something that helps reduce the implementation cost as well. There’s a number of other services that we’re looking at to do that. Again, trying to support that enterprise view, because part of it is about getting new customers, but part of it is also about retaining the customer base that we have and making that upgrade path a lot easier for them.

HIStalk Interviews Clay Johnston, MD, PhD, Dean, Dell Medical School

November 30, 2015 Interviews 1 Comment

S. Claiborne “Clay” Johnston, MD, PhD is dean of Dell Medical School at the University of Texas at Austin. Campus construction will be completed in May 2016 and the first medical school class will begin studies in June 2016.

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How have medical schools have changed over the last 20 years and how will the Dell Medical School will be even more different?

Medical schools are changing, and I think a little more rapidly now. They certainly haven’t changed as much as they should have.

The one realization is that lectures don’t work so well. There’s a lot more emphasis on flipped classroom type approaches to teaching, small group learning, that kind of thing.

More recently, too, there’s a greater appreciation of the fact that –  the way I learned was memorization focused, just cram all this knowledge. The reality is that information is cheap today. The resources available to physicians are much more accessible and are generally more accurate than memory for things that aren’t used frequently. Therefore, the need to memorize so much stuff is really not there.

There’s been some de-emphasis of that memorization task and more about how we find the data that we need, how we integrate that data, and how we use it solve problems. Those are some of the broader trends that are going on.

Obviously we want to take advantage of those, but also we’re coming without an existing curriculum. We have a lot more freedom than existing schools, where you always have people who defend the status quo and created that beautiful lecture set on the Krebs cycle and they’re just not going to let it go. We don’t have that, so that gives us a different perspective. 

For us, it’s more about, what is it that we want from health and from healthcare as a society? Then, what is the appropriate role of the physician in that ideal vision of what the health system should look like?  Then, how do we provide the best training to meet those needs, particularly given the problems in the health system? That completely opens your eyes in terms of thinking about, what is the skill set?

From our perspective, physician leadership is a big problem. Being able to look at system-level problems, work in teams, and use technologies and other new approaches to solving these system problems creatively. Those are some of the key things that physicians ought to be involved in. Not just to not resist them, which is a common problem now, but to actually help to lead them.

That’s what we’re doing. We’ve got a curriculum that’s very much designed around training these physician leaders of the future.

A significant percentage of medical school graduates either don’t follow with a residency or they take a non-patient care role after using up a class spot and the educational subsidy. How do you set reasonable expectations, especially as prospective students hear about burnout among practicing physicians?

We need to focus on why those physicians are burned out and look at the systems that have been put in place that have led to that burnout. One of the dysfunctions of the fee-for-service system is that it does not compensate people well for things like office visits or the cognitive aspects of medicine. It  does compensate well for procedures. Over time, the cognitive aspect reimbursements have been ratcheted down for physicians, so they’ve had to see more and more patients.

Then electronic health records were introduced. Their primary function today is billing. They have eroded even further the meaningful time that doctors spend with their patients. 

Those are just a couple of examples, but important ones for how we’ve made jobs like primary care really unpleasant. There’s very short visits — the average office is now 12 minutes. Up to half of that could be spent just documenting the visit in a very dysfunctional electronic health record.

The reasons that docs go into medicine have been lost. Having those meaningful, important discussions and time with patients is much more difficult today. 

How, then, do we change the system so that docs can spend more time with patients and maybe work with patients in whole new ways, you know, like email? It’s used in every industry. Why not allow patients to email their docs and make that part of the job of a physician to manage patients by whatever technologies make the most sense?

What do we tell our students? Well we tell our students, it’s your job to keep people healthy and to get them healthy again when they’re not. In the traditional approach, that was to be done in clinic visits and in ORs and emergency rooms. Now, open your eyes up and think about how you could do that best. If I gave you a panel of 3,000 patients to take care of, what would you put in place to make sure that they’re as absolutely healthy as they could possibly be and that you have meaningful discussions with them? 

You probably build a team around yourself. You would use technologies. OK, show me what that looks like. Tell me how we can build that and that there are ways to get paid for it. 

Medicine needs to evolve that way. Then the physician burnout also can go away because that perspective is just as important to fixing the health system.

Texas makes a lot of headlines related to telemedicine. Will telemedicine and other non-face-to-face technologies be part of your curriculum?

Yes. They need to be. To say that those technologies shouldn’t be important in the delivery of healthcare is just so short-sighted.

So many of the things that are currently addressed in office visits could be addressed much more readily by email. That opens up the possibility of more frequent interactions that can help patients who wonder, for example, whether a side effect they’re having is related to a new medicine they started. If we do that, then the office visits can be much more meaningful because you don’t need as many. 

There are definitely ways to easily imagine to push things forward, including telemedicine. Yes, we need to then engage our students in that.

Do you think the low-pay, high-workload model of medical residency that’s funded by federal taxpayers still makes sense?

It’s a strange model, but the reality is that the residents have two functions. They provide real work and help, which is why we feel like they deserve some salary, but they are primarily learners. They’re there to finish up their training. That’s in the best interest of society, to have that. 

Who should pay and how? It ends up the federal government actually pays for the minority of residents. Most are paid for through the hospital system. So it’s really, truly a strange, hybrid system. Could there be a better system? Probably. We do need to pay them something, but they don’t justify getting paid at the same level as physicians who have finished their residency.

Where in a physician’s career are the majority of concepts and treatment methods developed? How can a physician who has been out of school for 20 years remain as current as one who graduated five years ago?

I think that’s a learned behavior, not a deterministic one. I don’t think there is a point at which physicians are more difficult to teach. 

Physicians in general love their independence and love to be the final say in whatever it is that they work in. Traditionally, they’ve not been so comfortable changing over time. But honestly, if you look at systems, there have been some systems that have changed dramatically and pushed more to evidence-based medicine quite comfortably, where the physicians — a whole variety of different types within that system — move forward in lock step with the evidence. A good example is Kaiser Permanente.

I think there are processes and ways of working together and teaching each other and continuing to focus on education that can encourage those behaviors.

How much of medical practice is based on evidence and whose job is it to incorporate it ongoing?

Most of what we do in medicine, there’s not solid, high-quality evidence to support. It’s done because it seems reasonable, or it’s done because it’s always been done, that way or it’s done because the science underneath it seems to probably make sense, or it’s done because another patient was treated that way and did fine so it’s probably fine to continue. High-quality evidence — where you’ve got, for example, randomized trial data — that’s a minority of the decisions and weighty decisions that physicians make.

Currently it isn’t clear whose responsibility that is. I would say that physicians ultimately have the responsibility to practice based on the evidence, to stay current and to stay true to the evidence. But it is extremely difficult to do that in standard independent practice because things move so quickly and because it requires more adjudication than just reading papers. You have to really look at the papers in light of other evidence. You have to read the papers deeply. You have to think of the alternatives. 

That works better when groups of physicians and others come together to decide what standards they will practice under. Then the system really does have some responsibility for making sure that this can happen better.

In our case, we do feel like this is a responsibility that we have back to this community — to work with the excellent physicians here, but help them to stay excellent forever. How will we do that? We’re looking at ways. They need incentives to stay current. How do we work in creating those and then create those educational opportunities and also those arenas in which they can review and judge and decide on evidence that they should all follow.

How will you teach students to respect both traditional, large-scale, well-developed studies –which are often published only if the for-profit company sponsoring them likes the results — versus self-interpreted smaller data sets that will be available almost everywhere?

Obviously you have to teach them a lot more about how you look at data and what the issues are with it. The spectrum that you just described — be suspicious about Phase 2 clinical trials. Phase 3 clinical trials, those are so expensive that you have to publish it results from a Phase 3 clinical trial. That’s less likely, but the early-phase clinical trials — that is an important source of bias, as you say.

The individualization of care is the thing that was implied by your second question, you know, "These 10 people who look like you did well" — you don’t get that information necessarily from a clinical trial. You get it from a broader spectrum of folks who are eligible. They might do some sub-group analysis, but they’re never powered to adequately show a difference by sub-group.

Then obviously the problem with that evidence is that it’s weak. Maybe it’s luck that they all did well. Maybe doing well is an expected outcome, so it would be rare to actually have something bad happen. Maybe they were selected in a certain way that made them all do well. You can’t know.

How do you teach that? Data is going to be all around us and that’s a wonderful thing, because it gives us all kinds of additional information that if we’re careful, can be extremely useful in improving care, improving outcomes for our patients, keeping people healthier. 

We have to expose our students to that throughout the curriculum and get them involved in projects in which they’re using data to solve critical health problems. That’s what we do. We take them out of their rotations and they work for nine months in innovation and leadership blocks. They solve real health problems.

If the goal is to make our overall population healthier, what’s the right blend of what you  teach doctors to do as physicians in practicing medicine versus the public health approach that might include areas such as housing, education, income, or personal behavior?

It’s important for physicians to understand the full spectrum. Healthcare only accounts for 20 percent of the potential to improve health. Eighty percent of it comes from all that other stuff that you mentioned. If the goal of the physician is to keep people healthy, they need to be aware of that 80 percent and also understand how to integrate that into their practice or into their broader, system-level solutions to health problems.

The question is, where you draw the line? Are physicians going to be proponents of income equality because income differences lead to health issues? No, probably not. It’s not about getting to the political and the governmental aspects of the predictors. 

What if it is about diet and exercise? Those behaviors, or taking your meds — those are important things in which physician interventions or system-level interventions that could include a physician on the team are important things for the health system to focus on. It makes sense for physicians to have roles in those areas.

That stuff becomes critical to our curriculum. It is far more effective and can be cost saving to keep people healthier than it is to treat them once they are sick. The highest paid health professionals are physicians. Why shouldn’t they be engaged in that? Why shouldn’t they be helping to guide it rather than just been focused on the patch-up work?

Being in Austin and being associated with Dell suggests a focus on drug and technology research, but the product of such research is usually commercialized expensively without necessarily improving overall outcomes. How do you balance the human need for research with the desire of medical companies to make big profits and raise healthcare costs even more?

That’s one of the key reasons I’m here. I was the associate vice-chancellor of research and responsible for the Clinical and Translational Science Institute at UCSF. Our job was to accelerate discoveries from the laboratory out into health improvement. 

The reality was just as you said. We could keep doing that, but they’re going to be always maximally priced. They never lower cost, but they always elevate cost of care. That’s true — they have control of the pricing, so they price it to the point that it’s somewhere between $50,000 and $200,000 per quality-adjusted life year. That makes sense from their perspective to do that, but it just contributes to the problem where you’ve got so much cost that you can’t really afford innovation any more. 

That to me suggested, gosh, we’ve got to find a new way. What we’re trying to do is set up the health system to embrace and look for solutions that drive down cost. I think that we’ve left a lot of fruit low hanging on the trees because we haven’t had that perspective.

One example is antipsychotics. We know, as we’re looking at expensive health problems in Austin, the homeless — some of whom are schizophrenic — are a huge burden. Their outcomes are just terrible. It’s hard to get them to take their meds. It’s part of their disease. But if we had long-acting drugs, that could dramatically reduce the cost compared to what we pay today, with drugs that have to be given daily and are probably taken weekly if you’re lucky. That is an example of how taking a different perspective opens up new approaches, also for research.

Our hope is to integrate those perspectives throughout the research channels that we’re developing . We know we’ll have discoveries that come out and cost $200,000 per quality-adjusted life year, but our focus is to really concentrate on those that actually can reduce cost and improve outcomes.

It’s easy in the medical trenches to become disillusioned with what physicians are being asked to do, what issues they face that are beyond their control, and how the US healthcare system compares to countries that structure things differently. What will you tell students they need to do to improve it?

This is the absolute best time to go into medicine. We’ve gotten a point where we’re at the precipice — where physicians are unhappy, patients are unhappy, and we’re still costing the country a huge amount, 40 percent  more than Switzerland and that’s the next closest country. We’re at this crisis point. That means this is the time at which we can really push forward the creative solutions to healthcare. 

What are those solutions? Some are  easy to imagine, and as soon as we change the payment schemes, they become obvious and we’ll catch on. The payment schemes are changing. Some are not so obvious. It’s early days in what will be a really exciting point in medicine. I don’t think practicing medicine will look like it does today even 10 years from now.  I think it will be much more technology enabled, much more data enabled. The physician will be a true partner in improving health. That transition will be wonderful for those in practice and for the population.

HIStalk Interviews John Halamka, MD, CIO, BIDMC

November 23, 2015 Interviews 8 Comments

John D. Halamka, MD, MS, is chief information officer of Beth Israel Deaconess Medical Center and chief information officer and dean of technology at Harvard Medical School.

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What responses are you getting from your suggestion that Meaningful Use be dissolved and rolled into other CMS programs?

I would say 95 percent of the responses that I’m getting are very favorable. They say that the last five years has been like running a marathon every day. There’s a point at which you’re tired. You have to step back and say, "We’ve run a long distance." Now, how do we take that next step?

People of course say there’s some subtlety to moving forward, such as the Medicaid program was really about taking those without resources and funding them, as opposed to the Medicare program, which was initial funding followed by penalty. So when you say, “eliminate the program,” do you really mean no longer pay Medicaid providers to finish their implementations? 

That’s not at all what I meant. Which is to say, let’s get away from the idea of penalties on the Medicare side. Keep our Medicaid program still going, because if you’ve not finished your implementation, we’ve got to get that done. Instead of being highly prescriptive about the Medicare must-dos and the penalties resulting if you don’t, let’s offer some outcomes and let’s offer some variability. People have made that subtle comment.

One of the things they’ve also made a comment about is that I have recommended this FHIR standard. It’s something that is seemingly forward-looking. It’s the sort of thing Google and Amazon and Facebook would do. Some in the industry have said, yes, but there are some existent standards that are widely deployed. So maybe instead of just saying it must be FHIR and only FHIR, can you tolerate a transition period where some of the incumbent standards are used where they’re appropriate?

Of course. Being a reasonable person, I recognize change doesn’t happen overnight. You can’t go from a skateboard to a flying car. You might have some intermediate states. That’s recognized.

People have also commented, "Did you really mean to be negative about ONC?" What I tried to say … you write a lot, so you know it’s hard … I absolutely am not critical of any person. All I’m asking is, is the set of ideas, of getting very prescriptive and elaborative about the certification process, really a good idea? I think the answer with the certification rule is, it’s just too expansive in scope. It’s just  going to be too hard for stakeholders and especially developers to hit all the details that are in that rule.

The problem is that every time you give a developer an “or,” it means “and.” They’re going to say, "You could do it this way, or you could do it this way, or you could do it this way." There are customers who are going to ask for each of the variations. Really what it does is it takes our healthcare IT developers out of commission for a couple of years.

That’s really what I was getting at. People at ONC are very hard working and very well meaning, just probably as you pointed out early in the conversation have been so heads down in the details that they didn’t really look at the forest — they were looking at the bark. So, let’s step back.

Another thing that people have said is, "Did you really mean to eliminate all kinds of certification?" What I was getting at by saying let’s focus — if there were just three goals, maybe the right answer there is there’s still some kind of certification process, but it really is very narrow.

An example I can give you is if you went out to Best Buy today and you bought a DVD player, it will have a little Blu-ray symbol on it. You can expect that when you get it home and you plug in a Blu-ray disc, it will play. What I was saying is that we should focus on three things, such as can you use FHIR to do a push of data or a pull of data or get a patient to pull their data? You could imagine — of course I’m making this up as we go — that there are three little labels that you could be putting on the EHR package analogous to the Blu-ray label, so that you know when you got the package home, I will be able to push a payload to a trading partner or pull data from a foreign EHR.

Certification today is a multi-man year exercise where you are asked to enter a ZIP code and come back the next day and prove the ZIP code is still there. It’s just onerous, as opposed to a very narrowed set of, “When you take this home, it will do this.” Two or three things, not a thousand.

That’s the feedback. That’s the summary of what I’ve heard back.

You seem to be frustrated lately that the government is more involved in everything: HITECH, HIPAA, and  ICD-10, all enforced through Medicare. Do you think CMS has too much influence on what happens in the exam room between a provider and a patient?

I do. I’m not partisan in any way. It’s not that I have a Republican agenda or a Democratic agenda. I just try to have a multi-stakeholder agenda.

Here is an example. If Meaningful Use said, "We’re going to count the number of transactions you did,” but yet those transactions which I counted were actually not helpful to coordinate patient care or respectful of the patient’s wishes, was it really meaningful to count transactions? Here’s an example. You must, for a transition of care summary 5 percent of the time, ensure that from Provider A to Provider B, a package of stuff is sent. It turns out that package of stuff may be a bag of smelly garbage. That is, it’s 1,094 pages of completely unhelpful information, but I can count it in my numerator.

Wouldn’t a better measure be as a doctor, nurse, social worker, or physical therapist were you actually able to coordinate the care of this patient because you received the information that you thought was helpful to do so, somehow? As you know, I don’t have stock in any company. I don’t endorse any organization, so this is an exemplar. KLAS gathered together Cerner, Epic, eCW. Meditech, Athena, Surescripts, and others. If we want to look at the experience of data sharing rather than transaction counting, what questions would you ask?

Here’s a perfect example where the private sector said, we are very willing, in a Consumer Reports-like fashion, to have an independent entity call up 100 of our customers and ask them all these experiential questions which then will reflect — almost like a Yelp review — on the experience of interoperability with our product. That to me is a far better approach than CMS counting the number of bags of garbage that you sent.

What KLAS is proposing presumes that providers really want to share data with their competitors, at least on some occasions. Do you think customers are really demanding interoperability?

The United States has global capitated risk, bundled payments, and valued-based purchasing that’s been going on for five years in Massachusetts. Yet you go to the Midwest and there’s still fee-for-service.

Let me reflect on New England. We today at Beth Israel Deaconess have 1 billion dollars per year of bundled payment, risk-based contracts. We have told every doctor in our community it is not possible to manage risk unless we have, at every transition of care, about 150 data elements to understand what care was delivered. What’s the care plan? Who’s the care team? What’s the next bit of care the patient needs? What are the diseases we’re monitoring?

What you find, at least in our area, it isn’t even a question of siloed data, information blocking, or competitive whatever. It is an existential question. If you do not share data, you can’t survive, because we are paid for wellness, not sickness. I think a much more potent motivator than Meaningful Use or stimulus or compliance or penalty is this idea of, I will pay you when the patient is healthy or give you a fixed amount to keep them healthy. That eliminates these competitive kinds of barriers in information exchange.

Health systems haven’t done a good job at managing wellness or overall health outside of their own facilities. Are they capable of making the change from episode-driven care to population health management?

I just looked at our Pioneer ACO experience. I recognize that the Pioneer ACO program has very mixed outcomes. But at least at Beth Israel Deaconess, where we have 450 locations of care, we have gone beyond what we would call the EHR and now focus on the care management medical record. 

At our ACO, we have a single, normalized database that receives all the Meaningful Use transactions from every one of our clinicians and hospitals and urgent cares and SNFs and all the rest. Then the care managers are looking for variation. They’re looking for gaps in care. They’re looking for opportunities. They’re looking at risk and these sorts of things. 

I’m told we’re the #3 ACO in the country and the #1 in New England because of our capacity to reduce cost and improve quality with this care management medical record approach. You’re correct that the off-the-shelf products that exist today don’t do that very well, but it is certainly possible to use technology to accomplish the goals of, as MACRA will suggest, value-based purchasing.

The mainstream press and politicians seem to be paying attention the reactive phrases “gag clauses” and “information blocking.” Are big health systems using their EHRs to reinforce their market power?

When I say I’ve never seen information blocking — this is like the Loch Ness Monster, often talked about, but never seen — people do comment that information blocking can take many forms. Like a hospital that is technically not capable of sending information or a hospital that is 200 miles away from a referring physician and hasn’t quite got to the data transmission to those in the periphery. Again, speaking from Massachusetts, I have not seen hospitals and doctors use information blocking as a competitive weapon, thinking that if it’s my data, I will retain the patient and I will make more money.

In fact, I’ve quite seen the opposite. That is, there is this sense that if I need data for managing care and you need data for managing care, we had better bilaterally exchange data because it is no longer a competitive advantage to maintain a data silo.

The only time I’ve seen sluggishness in the transmission of data are for the reasons that I mentioned. That is, technically maybe a vendor or an IT department isn’t quite familiar with the technology. Or that there’s a Pareto diagram of all the clinicians we interact with and we’re going to start with the ones that are close, while the ones that are 200 miles away, we’ll get to. It’s not volitional. It’s just a function of resource.

What do you think of ONC’s proposed health IT safety center?

I have to read more about that. As I’ve read the various presentations about it, the concern that we have is that as we introduce new processes and technology, sometimes we create new errors and that we don’t really discuss those new errors in an open way. In New England, we have a patient safety organization which comes together to openly discuss these in a what I call a blame-free environment. I think that’s the notion of what ONC is trying to do at a national level.

I’ll give you a silly example. It’s not true, but it would illustrate the problem. If you came to me with high blood pressure and I wrote you for atenolol, which begins with A-T, I would never on a piece of paper write anything other than atenolol. Of course you couldn’t read it, but it would say atenolol. Whereas if I had an EHR that had a Google-like look-ahead feature and I started typing A-T and the first thing that came up was Ativan and I clicked on it and I was giving you Ativan, I’m giving you now something that’s an antianxiety drug instead of an antihypertensive.

That is a an error of commission. That is an error of technology that would have never happened in a manual process. I think those are the sorts of things that we identify locally in Harvard that ONC wants to see at a national level and Congress wants to see at a national level, enumerated and fixed.

Are EHRs poorly designed or are doctors just unhappy with the information insurance companies and the government require before writing them a check?

Probably there are a couple of answers to that. This usability question … I’m sure you’ve heard many, many people quote Justice Potter: "I have no idea what usability is, but I know it when I see it." Having an objective metric of usability … NIST is trying, but it’s hard.

Why are there usability challenges? I could argue Meaningful Use itself creates usability challenges. If, for example, there is a quality measure that says I must, in my denominator, only include people that have had strokes less than two hours ago. "Mrs. Smith, did your husband start talking funny one hour and 59 minutes about or two hours and one minute ago?" I now need to literally build a pop-up in the middle of my EHR workflow with a question about the timing of the stroke. It would never be part of my normal clinical data workflow.

As we do all these quality measures, as we do more and more structured data capture, what you find is that these vendors are having to add on all of these fields outside of workflow. That creates enormous usability problems.

One of the members of the Standards Committee said that they had actually done a usability analysis of how many clicks a nurse must use to admit a new patient and to document that new patient admission. The answer was 523. That was really just a function of all the regulatory mandates that require all the structured data capture.

I think we would all agree that each of the federal mandates on its own is a noble thing. All of us think domestic violence should be identified and treated, but that is just one of 100 structured things you ask on admission, "Do you feel safe at home?" That just creates real usability burden. Of course, one asks, are there other ways one can do this, such as a natural language processing or ways in which a free text entry is parsed by a computer and the clicks are reduced?

One of the things that I have suggested to Karen DeSalvo — and I think she recognizes it as a good idea —is maybe a certification criterion for the future is, “Did you eliminate the number of clicks by 50 percent?” Part of that has to be that the regulations were simplified so that we could.

I always assume that if one EHR requires 523 clicks, others might be 518 or 591. It’s not as though one vendor approaches things so differently that only they have problem with the number of clicks.

I would agree with you. Although, I live in a Web-mobile world. If you look at the user possibilities in a Web-based or mobile-friendly framework versus one that was more based on a client-server framework, I think you can probably achieve a better user experience on the Web than client-server. Many, many people debate that and I have no objective evidence to back it up, so it’s purely my bias. 

First, reduce regulation. Secondly, as we move to different kinds of technologies on the client side, probably the user experience will be enhanced.

Direct messaging never seemed to get the traction people expected, maybe because nobody ever took the responsibility to publish and manage a Direct address directory. Does Direct still have relevance in interoperability?

Here was the problem with Direct. As you say, whatever we chose — it could have been FTP, it could have been REST, it could have been SMTP — it depends on an ecosystem, not a standard. Dave McCallie, I think, wrote a guest post on my blog saying, “Standards are necessary, but insufficient.” So to say, “We will mandate Direct" was a lot like saying, "We will mandate you to drive a car, but we won’t have any highways.” How come you aren’t driving? Well, let’s see. We don’t have road signs and we don’t have maps. We don’t have any laws or governance. It’s pretty hard to drive. 

What should have happened with Direct is it should not have been mandated as fast as it was. It should have been encouraged and an ecosystem developed first. You’ve seen what I’ve written about things like a provider directory. It’s pretty hard to have successful Direct messaging in a community unless somebody has a directory of places to message to. DirectTrust, of course, is trying to work on the directory and certificate bundles and that sort of thing. When the Meaningful Use Stage 2 requirement was launched, DirectTrust didn’t have all that stuff built. Surescripts is trying to do the same thing.

You’re starting to see private industry building the missing enablers. As I wrote in the blog piece, some enablers may be government based. Some may be private industry based. Or you might have both. But it’s pretty hard to mandate the Direct protocol before the enablers exist.

Healthcare IT always gets stuck with some mandate that moves us sideways instead of forward. Are you concerned that we’ll chase data security with nothing really different than it was before?

You might guess that I spend a vast amount of my time on information and security. The challenge is, I mean, sure, go invest $5 million in technology. That won’t help you so much. You are going to be as vulnerable as your most gullible employee. What we’ve found is that you must invest, sure, in detection, prevention, and all the good things like firewalls, antivirus, and malware prevention, that sort of thing. But you also must educate every member of your workforce and you really have to reinforce that education.

For example, we have an internal, self-created phishing campaign that we use to test our employees’ knowledge of, “I just emailed you a password reset message with a URL in China. Did you click on it or not?” Of course, beyond that, you need very good policies, policies that people can actually comprehend. When I tell you, "You had better not show up at work with an unencrypted device," what does that mean? What kind of encryption? How do I do it? Be very specific. It’s hard to hold employees accountable for doing the right thing unless you show them how to do the right thing.

I tell people security is a process that will never be done. It isn’t a discrete project that you do once and forget. It’s technology. It’s education and policy. We can do it, as you say. It’s certainly an effort. It takes a lot of resource, but done right — and I think we can do it right — it’s an enabler.

Some of your CIO peers have told me they don’t stand a chance in trying to defend against a nationally sponsored, sophisticated cyberattack. Does government have a role or can something else be done to help individual health systems protect themselves?

There’s probably a couple of answers to that. Threat notification — that’s certainly important. That’s where, yes, the government has now crossed multiple industries, tried to create enabling legislation to share cybersecurity threats and vulnerabilities and do that in a way that can protect us all. So yes, we probably need to do that.

Harvard was attacked by Anonymous in 2014 with a massive distributed denial of service attack. This was published in The Globe, so I’m not revealing anything that is a secret. Was Harvard ready for a massive denial of service attack by a hacktivist group? That wasn’t one of the threats that anyone had enumerated as likely. So sure, the government can help us with that. If there is a mechanism of using government to help with forensics when you’re getting these kinds of attacks that are virulent and new, probably the government has more resources than an individual hospital.

I suppose one thing I would say is enforcement by OCR and OIG and other folks has to be done with an eye to, what is the community standard? If I see you as a patient and I do everything per the community standard but you still die … I mean you could sue me, I suppose, but generally malpractice looks at, was the standard of care followed, regardless of outcome achieved? If I put in intrusion detection and prevention and malware this and that and mobile encryption but still a state-sponsored cyberterrorist penetrates me? Probably I did everything I should have and I couldn’t defend again this highly virulent attack. Not my fault. You sort of hope OIG and OCR and others recognize it’s a community standard question not a, “I avoided all breaches forever,” because we will never all avoid breaches.

Do HIPAA fines and regulatory action need to be changed in some way to be less punitive and more constructive?

I certainly think that government regulators have to enforce based on volitional, “I spilled data because I actually gave it to somebody that I shouldn’t have,” or what I’ll call egregious malpractice. "I bought a wireless access point at Best Buy and put it on my data center," as opposed to, “I’ve had two publicly reported breaches over the last two years, neither of which I could control.”

As an example, if a doctor goes out to the Apple store and buys a device and thinks that adding a password to the device is the same as encryption and then the device is stolen but it was a device I didn’t even know about. Of course today, I the CIO am accountable for this device purchased at the Apple store that wasn’t encrypted. Of course, we do everything we can to now educate and anything we buy we encrypt, and all the rest. We did our best.

So, guys, what should we do? Tackle every individual who enters our building carrying a non-encrypted technological device? It’s not technologically possible. Recognize that there are gradations of things we can do and can’t do. Hold us accountable for the things we can do and recognize that education is often the best we can do in many circumstances and decide that that’s OK.

You mentioned in your write-up about the Meaningful Use program that it may have stifled innovation. What kind of innovation do you think healthcare or healthcare IT needs and what’s the best way to achieve it?

I have 19 developers total at Beth Israel Deaconess. Remember, we still self-build our EHR. It isn’t that Epic and Cerner and Meditech and Athena and eClinicalWorks or whoever are doing a bad job. It’s just that the kind of things that our clinicians have demanded and the prices we can afford to pay mean that building still works for us.

Look at the Meaningful Use “Statement of Burden.” I’m sure you’ve read all those thousands of pages. You look at these burdens like, “It will only take you 30 man-years to certify your EHR.” You’re like, "I have 19 people, total." Instead of working on Apple Watch medication reconciliation for elders in their home, I am now doing certification scripts. That’s where it has truly paralyzed my development shop for the last three years.

The kinds of things that our patients are asking for are more mobile technologies, more patient and family engagement, more what I’ll call family decision support, better access to information. There’s all these things that you would think, “Oh, if we were a customer service-driven organization, we would naturally offer them.“ But we have a choice — customer demand or federal regulatory stimulus and penalty. For the moment, we’ve got to go with regulatory demands.

People will then criticize me and that’s OK, saying "See, you shouldn’t self-develop. You should just go buy Epic and Cerner or whatever.” That’s fine, but Beth Israel Deaconess for 30 years has had this idea that innovation happens in the trenches, and that probably it’s a good idea to have a doctor code and come up with something that is solving a problem they saw today rather than wait a few years for a vendor to include it as a feature. Wouldn’t you love to have doctors and pharmacists and nurses and social workers creating software that solves real-world problems? Isn’t that the kind of innovation that we want to support?

What patient-facing technologies are you using or considering?

Recently we launched a program in our ICUs called MyICU. You’re familiar with various patient portals and these sorts of things. If you’ve ever had a loved one in an ICU or been in an ICU yourself, you know there’s a dizzying amount of data, but not a whole lot of information and wisdom.

What we’ve done is create an iPad app that shows patients and families –we’ve just written a paper that you’ll see published in JAMIA shortly about how we decide, based on patient privacy preferences, to share information with what family members and how does that work if the patient is intubated debated and that sort of thing – but it’s essentially a real-time dashboard saying, here are the goals that you have for today in this hospitalization. Here are your preferences for care. Here’s how the patient is doing against those goals. Here are the events of today. You’ve built this closed-loop information system with messaging back and forth between care team and patient and real-time interpretation of data into wisdom. Suddenly patients and families are saying, wow, I’m really an equal partner in my care here.

My father died two years ago and was in an ICU. Of course they said, "You know, his ejection fraction is 20 percent and his O2 sat on a non-rebreather is 82 percent and his creatinine has gone from three to five." Of course my mother goes, "Uh, and?" This app wouldn’t show you that. It would say the goal was to get him off a ventilator and that’s now red, so things aren’t looking so great. Or, we want to make sure that his organs are doing well, but that’s red, so they’re not. The kind of thing we’re focused on is not just raw data, but wisdom.

Is it hard to reconcile the science of informatics that could be versus the reality of what has to be?

Doug Fridsma, who is now the CEO of AMIA, and I had this discussion during the conference. He said that AMIA is striving to pivot from being a research-oriented group — the sort of folks that are in a lab and they’re more or less trying to push the envelope of possible — to a gathering of applied informaticians who are asking, how do you take Epic and optimize the care plan? Or, how do you take Cerner and do population health?

It’s exactly the point you make, that it’s probably a great use of all the smart people in our country to optimize the things we are seeing in the trenches as opposed to just work in the laboratory. That’s really what they want to do.

Do you have any final thoughts?

You may glean from some of my writing that there’s a hint of pessimism. We have been overwhelmed with Meaningful Use, ICD-10, the HIPAA Omnibus rule, and the ACA. The government has co-opted our agenda. Many of those great people in government who we worked with early in the Obama administration when there was hope and change have left.

I want to make sure the readers know that I’m incredibly optimistic about the future. What I see is that we are going from an era where we’re following regulatory requirements to an era where we, in theory, will be incented to innovate based on new kinds of payment models. Therefore, we actually will see – not one top-down command and control, this is what you must do, enumerated list of prescriptive regulations – but if you want to give all the 80-year-olds Apple Watches and monitor their vital signs and have visiting nurses come to their homes and keep them out of the hospital, we’ll reward you for that. Oh, but you don’t like Apple Watch? That’s OK, you can do something else.

I really feel that we’re on this cusp of moving to a new kind of work where we’re going to run lots of pilots. We’re going to learn. That’s really, I think, what the Institute of Medicine ultimately wants us in the next 10 years to be, is this learning healthcare system that tried a lot of things. Many of them will fail, but when they succeed, we’ll share them broadly.

That’s why I maintain my optimism. That’s why I come to work every day. That’s why, after 20-some years, I’m still a CIO.

HIStalk Interviews Michael Pirron, CEO, Impact Makers

November 18, 2015 Interviews 3 Comments

Michael Pirron, MBA, PMP is founder and CEO of Impact Makers of Richmond, VA.

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Tell me about yourself and the company.

I am a former Andersen Consulting professional who has done both an undergraduate degree and MBA at Kellogg School of Management at Northwestern.

Impact Makers is an IT consulting firm, fully owned by two public charities. If we’re sold, all proceeds from that sale will go to make in-perpetuity community  impact as well as to impact investments in social enterprises.

Our work is project and program management, process improvement work, management consulting for the CIO, governance risk and compliance, and security work. Also digital strategy and mobile and web implementation. The majority of our work is in the healthcare space, both payer and provider, as well as healthcare governmental agencies.

Why would a for-profit company donate all of its profit to charity?

I guess it started with me. I’ll take full blame. I was fascinated in my undergraduate degree with reading a business case on Newman’s Own. We are essentially the Newman’s Own of IT consulting. Newman’s Own is Paul Newman on the side of salad dressing, but they’re a for-profit company that gives all profits to charity and is fully owned by a foundation. I was fascinated by that business case.

I went to work with Andersen Consulting, overseas mostly, and found that I was good at what I did. But I wasn’t necessarily values-aligned with some of our clients that I worked at. As well, the company culture tended to be very money-focused and individual-focused. I found it compelling to think of an idea of creating an Andersen Consulting on the Newman’s Own model. I wrote a paper about it when I went to do my MBA with that in mind.

Non-profits and government do a lot in the world to solve social and environmental problems. I am a capitalist. I have business degrees. But figuring out how to use the power of the free market to solve social and environmental problems instead of  government handouts or non-profits is something that spoke to me. It has actually gotten bipartisan support, which doesn’t happen much these days in the world.

I guess that’s the purpose. How do you transform individuals’ skills, experience, and training through their professional work every day to not just deliver client value and do all the things of job creation that any other for-profit would do, but also not be just a good steward in the world, but actually make a real impact in the world at the same time. Then what does that do for our employees in terms of personal growth and satisfaction? Not just job satisfaction, but speaking to everyone’s desire to leave the world a better place than the way they found it.

It’s interesting that your company is a for-profit that acts like a non-profit, while your non-profit health system customers make dozens of millions of dollars just like a for-profit company. Does it seem strange to explain to a non-profit health system what it’s like being a mission-driven organization?

That’s why healthcare has worked so well for us. So many people in the healthcare industry really care about patients, really care about patient outcomes, and have a deep culture of caring for their members and patients. That culture of caring and wanting to make a difference is pervasive in healthcare. It’s the reason we like working in the healthcare space and why it’s been such a good market for us.

It’s obviously an easy sell to the non-profit healthcare organizations we’ve worked with, although I would say it’s probably about 50-50 in terms of nonprofit and for-profit. We work with large national payers, providers, and healthcare government agencies. Probably a little bit more than half are on the non-profit or governmental side. Newman’s Own, which is a wonderful organization, sells using not just that it has a good product, but it uses cause-based marketing. There’s this class of conscientious consumers that buys socially impactful products.

We’re B to B — we’re not B to C — and we’re services. Our clients buy on capabilities and price. While our model is interesting to C-level folks who care about the company’s community impact footprint, really we’re competing on capabilities and price. As a for-profit company, I think that’s a good thing.

Sixty percent of our work comes from existing clients. It might get us in the door to talk to a C-level person or it might be a tie-breaker on a competitive bid, but that hasn’t been the reason we’ve won work. Although there’s been this immediate mission alignment with some of our non-profit healthcare partners, as you mentioned, which I think helps with the relationship long-term.

An article announcing that you’ve been named to the Inner City 100 list of fastest-growing inner city businesses had a picture of your cool offices. What attracts an employee to a fun, urban location instead of a faceless glass building in a suburban office park?

We’re in Richmond, Virginia, in a warehouse district that’s being renovated. All the warehouses are being turned into breweries and various interesting businesses. It is also a big hipster community. It’s a trendy area in Richmond, which is a wonderful place, You don’t always associate Richmond, Virginia — the home of the Confederacy — with hipsters.

It’s a really neat space. It’s accessible to public transportation. We have solar panels on our roof, which provide 25 percent of our electricity. It was aligned with being in the city. It was aligned with our values and with environmental impact standards. We’re founding B Corp, so we try to not just focus on social impact, but environmental impact and all of those things as well.

It was a good space. It was aligned with our values and aligned with a lot of our staff’s values. It’s an open office environment. People like to work in the space. Although our clients don’t hire us for our model as an IT consulting firm, we’ve had amazing retention. We’ve been Inc. 500 three years in a row and  Inc. 5000 four years in a row. 

The reason we’ve been successful isn’t our model, but because employees want to come work for us and stay. We’ve had 10 people leave in nine years. If you know the IT consulting industry, that’s an unbelievably amazing retention rate. People want to work for a company that’s mission-valued, mission-aligned. That creates values for our clients because our clients get employees that stay for the entire duration of a project. Mission-aligned teams outperform ones that aren’t mission-aligned, all else being equal.

What’s the state of healthcare IT consulting compared to a couple of years ago when everybody was mostly focused on Meaningful Use and ICD-10?

We’re seeing this tremendous interest in transformation, as a keyword, caused by a bigger interest in consumer-focused healthcare and this whole interest in the Triple Aim concept that we’re seeing from our clients – quality, access, and reliability. Those things combined are creating this enormous interest in transformation, whether that’s digital transformation or even just core operational function. Looking holistically at the organization, doing organizational assessment work to align around those goals and values.There’s also the obvious trend of mergers and acquisitions going on across the space.

Those three things — Triple Aim, mergers and acquisitions, and the focus of on consumer-focused healthcare – are revolutionizing the space and creating these large transformation projects that look across security, digital, organizational structure, and how to best align both from an IT perspective as well as a business perspective for delivery. We’ve been really focused on these large, enterprise-wide transformation projects for assessing, planning, designing, implementing these efforts and managing the delivery of those efforts.

Slow-moving and change-resistant health systems are being asked to respond quickly and to assimilate cultures thrown together by merger and acquisition. What are they doing to address their cultural lethargy?

I think it’s streamlining. We’re helping both payers and providers in these transformational roadmaps. We’re seeing a common denominator being, whether it’s Triple Aim or others, that technology needs to provide the right customer engagement, the right information at the right time with optimal cost. It all sounds so obvious, but as you said, they’re really moving into a brave new world that maybe other industries has already transformed themselves and healthcare is being pulled into that same transition.

Providers are suddenly interested in patient engagement now that there’s a financial carrot in place. Why did it take so long to bring patients to the table?

We’re seeing governmental programs and payers creating a financial incentive for providers – whether it’s accountable care organizations, medical homes, or any of the various models – in paying for performance and paying for outcomes. Those things require direct patient engagement and consumer focus, almost like a retail organization would. They need to be creative and not only to do the right thing for the patient, also to be successful financially.

What are providers doing to change from a "here we are, come knock on our door to get services” model to reaching out like a traditional company might do?

There are a number of trends. The one that we’ve been focused on is making sure that we make that connection between the patient and provider. Not the hospital provider, but the individual physician or specialist. Interactive smart provider search engines that are very specific and unique that  make sure the patient with the right keywords get to the right specialist they’re looking for at the right time. Trying to make sure that that interaction happens. For health systems, that it’s the physician that’s within their health system. There’s a desire to ensure the patient stays within the system.

Secondly, using mobile technology to interact with the physician specialist and patients in a way that enhances clinical outcomes. It has to be a secure way, of course.

Those are the areas where we focused within the digital framework to ensure consumer engagement.

Short of changing their business structure, what can companies do to make a social difference beyond the usual employee volunteer day?

We have the ownership structure, but we also give up to 30 percent of our operating margin away to local charitable organizations that are secular, apolitical, 501(c)(3), local to where we do work, and that help people help themselves. We’re governed by a volunteer board. I’m the founder of the company, but I don’t own any of it. Our volunteer board chooses these partners.

Whether you give 30 percent or 10 percent, choose mission-aligned partners that might be aligned in the healthcare space — if you’re doing healthcare consulting  — to support. Make that part of your brand. That’s meaningful to employees. You don’t have to do 100 percent over the life of the company like we do. Even 10 percent or 15 percent is meaningful. Doing good is good business, too. It adds to the value of the brand. It adds to your own employee engagement in what you’re doing.

We also do pro bono consulting for our charitable partners. Having employees being able to, during work hours, work at client sites is meaningful to employees and is a benefit to employees and creates community impact. Having a mission and leading with values. We started with mission and then our values came from that. That’s been the true reason why we’ve been successful, because we are absolutely values-based. Doing the right thing is critical for both clients and employees.

Our executive team says, do the right thing for our client. Do the right thing ethically and morally. If you have to make a decision with the client without going up the chain and you do it, as long as you do the right thing, we’ve got your back.

Having those strong values and articulating those values often. Our performance review process is tied starting to our values at the highest level, and everything follows from there. We repeat that often at every company meeting.

Then the final thing is we’re a founding B corporation, which is a certification standard for companies that aren’t just about making profit, but also taking into consideration the environment, employees, and community and aren’t just about maximizing shareholder value, although they’re all for-profit companies. Companies like Patagonia, Ben and Jerry’s, and Etsy that just went public are shining examples of B corporations. It’s a community, internationally now, of 1,400 companies that are focused on making a difference using the power of the free market to solve social and environmental problems. Any company that has a mission to make a difference can consider that to be part of something bigger than just the company that they’re doing and help spread that ethos within business.

Do you have any final thoughts?

What we’re doing is pretty game-changing. It’s pretty disruptive, actually. If you think about what we’re doing, we’re a group of middle-class professionals doing the same work we’ve always done, but structuring it differently, and collectively making the same impact in the community as foundations, and eventually large foundations.

Our goal is to have, in the next seven to 10 years, a sale of the company that puts $120 million into these foundations that will make in-perpetuity impact and create more Impact Makers through the investments that they do. Not doing it at the expense of employees, because we pay market salaries to employees, and have employees share a little bit in the value that’s created. At the same, have a way to raise capital from the capital markets. We’re in the process of raising preferred stock equity in a way that is still aligned with our model and is largely from the non-profit world.

If we can solve that, that’s creating a new model that no one has ever done before. It’s democratizing philanthropy in a way that’s not even done. I think that’s the disruption, that group of middle class professionals structuring things differently and collectively making an impact in the community like has never been done before.

HIStalk Interviews Joshua Mandel, MD, Harvard Medical School

November 11, 2015 Interviews 2 Comments

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.

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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

October 26, 2015 Interviews 3 Comments

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

October 12, 2015 Interviews 2 Comments

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

October 5, 2015 Interviews No Comments

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

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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.

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Reader Comments

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