A reader suggested that we might want to talk to Joel Diamond MD, chief medical officer for dbMotion, practicing family physician, and a former CMIO with UPMC. “You should try to interview Joel – he is smart and funny and really knows his stuff.”
Joel is working on an $84 million initiative to jointly create a healthcare interoperability model that will use dbMotion’s technology to connect clinicians across UPMC’s 19 hospitals and 400 outpatient sites and doctor offices. Thanks to Joel Diamond for sharing his thoughts with the readers of HIStalk.
Inga: OK, you ready to go?
Joel: Yes, though I am really nervous. Is this really Inga? [laughs]
[Laughs] Yes, but don’t be nervous. So, you do read HIStalk?
All the time. I am a huge fan.
So, you came from UPMC where you were CMIO. What led to your decision to move to dbMotion?
I have been following the interoperability plans for UPMC for a very, very long time ever since I was involved in establishing UPMC’s CPOE at one of UPMC’s remote hospitals. After the success of CPOE and other projects, it was clear that interoperability was the solution of the future. I dug in and learned about dbMotion. When I found they were looking for a medical director in the US, I jumped on the opportunity. dbMotion is great and it is a fun job.
Tell me about your position as CMO with dbMotion. What type of activities are you involved with?
The bulk of my work is this massive UPMC project, which has two separate parts to it. First, the core interoperability project itself. There is a lot of work to be done here in terms of customizing the physician views and integrating the multiple disparate platforms. The UPMC project itself is massive because we are trying to interface many, many disparate systems.
Also there is a joint development project between db and UPMC that is just getting off the ground. We are trying to develop a product to enhance patient safety issues. Trying to have the product reflect the needs of individual clinicians is one of our major goals.
In October, dbMotion and UPMC announced an agreement to create a joint development partnership. What is the scope of the project?
It is centered around a product called SmartWatch. SmartWatch is focused on looking at populations of patients and then being able to get lots of disparate data and then turn it into something actionable. For instance, we could define what child abuse might be and what to look for, and then put in certain parameters in order to monitor it. Patients with certain characteristics can be found and then you are able to report it to a particular organization or entity. Or it might involve bio-surveillance on a large scale.
We have a couple of use cases we are developing with UPMC. One of them involves transfer of care. When going from one venue to another, determining what needs to be done to ensure that the handoff is done properly and the patient information is collated properly. One of the other use cases is readiness assessment. If a patient has to schedule a procedure, then determining everything that needs to be done on an administrative level and making sure it is done. Third is chronic disease management and it will likely center around diabetes.
Are you involved with any of the international projects that dbMotion is working on?
No, because we have a CMO of dbmotion in Israel, Dr. Ran Goshen, who oversees all those projects.
What about any non-UPMC activities?
Dr. Diamond: Some with the Bronx RHIO project that is underway and has an expected go live in May of ‘08. I am also involved in the evaluation of new business opportunities in the US market.
Are you also visiting potential clients?
Yes, as well as trying to explore new areas where dbMotion might be needed other than what we have been focused on.
There have been a number of announcements over the last few months of RHIO efforts that have failed, either due to financial issues or lack of support from the community. Does that concern you?
It really doesn’t. It really isn’t a surprise. If you look at the Gartner’s Hype Cycle, we are at the Trough of Disillusionment. There had been some unrealistic expectations. We are now much more realistic about what RHIOs can do.
I am not pessimistic about RHIOs all. I think our focus will change a little bit. A lot of people set out to do RHIOs, but didn’t have the technology to do it. I think that is where dbMotion makes a difference.
Who does dbMotion see as competitors?
A lot of people are in the so-called interoperability space, but we don’t necessarily see them as competitors because they have a very different focus than us. A lot of people are in the portal space and that is more of a forum to view information. There are several companies trying to collect data to see in a single space. dbMotion is different because we have the Unified Medical Schema and we are focused on aggregation and integration of data.
So, explain to me how dbMotion is different than a company like Healthvision?
dbMotion has very, very unique architecture that allows it to handle a lot of the complicated interoperability issues in a very, very short time. It has a broad and deep reach. We are not a product that just has the ability to point you to the information you need or just display data you need.
In a true schematic operability, you can exchange information because they have a common understanding. You may link up a disparate system that has different terminology for the same diagnosis. We have the ability to take the data and present it as a single common knowledge piece and do whatever needs to be done. It can be used by an individual in a format that is meaningful.
The other thing that is different is that if you are just presenting data, it becomes a very huge list for people to scroll through. A large data dump may discourage users from using it. Looking at a list of allergies, you may overlook important data if you don’t present the information in a format that is relevant to the physician. Our technology allows the information to be displayed in a more meaningful format. It also helps with patient safety.
Why are UPMC’s interoperability projects surviving?
There has been a tremendous vision from the start. In addition to that, the people involved in the project, from IT to doctors and nurses, have really kept the focus on the entire project more on a quality. So, focus plus talented people, and then they keep building on their successes. They have also had a very steady and well-constructed ambulatory project for EMRs that has allowed for integration of all the data, along with a goal of improving patient safety.
So the goals are good and people are good.
Yes, and they haven’t been afraid to change their course when appropriate. They realized at some point that having a one-size-fits-all model was not going to be sustainable. At that point, they realized they needed multiple solutions and needed some central ability to control the processes. And that is when the decision was made to partner with dbMotion.
I understand that in addition to your work with dbMotion you are still seeing patients. How do you balance your dbMotion work and your clinical activities?
Yes, I am still seeing patients. I am balancing it very carefully. [laughs] I need to maintain seeing patients on a personal level because I enjoy it so much. And, two, without seeing patients, I am not sure I can maintain credibility and an understanding of physician needs.
Having an EMR for so many years provides me access to my patients’ information in so many ways. I have a patient portal and use e-prescribing. Many of my patients I have known for years have access to me by cell phone 24×7, so my situation doesn’t mean they have any less access to me. I work one full and very long day in the office seeing patients.
You spent some time working with Misys in an advisory role for their EMR and CPR products. Any thoughts on the recent changes, including selling off the hospital pieces and re-selling the iMedica product?
I have mixed emotions on the CPR sale. I think it will help their focus. There were so many great people associated with that product. I think it was one of the best products I had ever seen.
I can’t comment on the business reasons and whether it was a good decision. But the product isn’t going away, so that is good. And, I wouldn’t know enough about the iMedica situation to comment about it at this point. I will say that Misys’ focus on the community is a very, very smart play.
Who do you admire in the industry?
Hmmm… Mr. HIStalk and Inga? It is a very, very long list after Inga and Mr. HIStalk.
Nick Jacobs isn’t just a popular blogger. He’s also president and CEO of Windber Research Institute and Windber Medical Center of Windber, PA. A couple of readers suggested I talk to Nick about small-hospital technology. If you think that’s an oxymoron, read on about what this tiny rural hospital of a few dozen beds is doing.
Thanks to Nick for the chat.
Tell me about Windber and about yourself.
The hospital is 101 years old, started specially as a hospital to take care of the coal miners for the 40+ coal mines of the Berwind-White Coal Company. When the town of Windber was constructed, it was seen as what would be a model town for the industrial revolution. Every house had a central heating system provided by the coal company, schools, hospitals, and churches. It was like the Celebration community in Orlando. The commitment was made that this hospital would be one of the most outstanding in the US.
For the first 40 years, the starting physicians were innovators, to the point they held numerous patents and successes. They studied with the Mayo brothers, like learning to remove the thyroid without leaving scar. Celebrities came for the surgery, like Betty Grable, Arthur Godfrey, and Jeanne Woolworth.
We’re 30 seconds from where Flight 93 went down. I came in 1997. We have 550 employees now and a $21 million payroll.
The issue for me when I came was that the hospital had been given a death certificate by Ernst and Young. In the coming era of capitated managed care, the hospital had a short life left. That gave me a chance to challenge my board. I told them, “We can let it go, or we can try to go back to innovation and technical advancement and high-touch care.”
We had the first hospice in the US, founded in 1977, for a rural area. I was able to use that as a model for physicians and the board, telling them, “Look how people are treated in the hospice. I want to take this hospital-wide.” We’re a Planetree hospital now, the third in the US of what is now 200. We embraced the concept of spiritual, holistic, mind-body-spirit care, the highest touch concept.
Having interviewed at Boys Town Hospital in Omaha in 1992, I got to a hospital that looked like Windber but was called National Research Hospital. I asked a priest why. He had 38 PhDs and was a genomics center in 1992. I found myself at a dinner party with our local Congressman talking about the Dean Ornish CAD Reversal Program. I explained it to him. He said, “We’re spending $1 billion a year on heart disease in the military.” We launched partnership with Walter Reed the following year.
Then, a board member got breast cancer and came to our hospital. That made me uncomfortable. I wondered why she didn’t go to Sloane-Kettering or MD Anderson. She went through it at our place, then went there for a second opinion. She went to our Congressman and said, “These guys have figured it out.” We have massage therapy, popcorn, clowns, family access, everything. She told the Congressman that the military was spending all that money, but nothing in our district.
We built a research facility with 50 scientists and 40,000 of the most highly annotated breast cancer tissue samples. These are longitudinal studies because they’re in the military. We built a team of biomedical informaticists who have perfected software and methodologies for mining huge quantities of medical-related data.
Because I’d never worked in a research institute, and in fact didn’t get into healthcare until I was 40 because I was a high school band director, one thing I discovered is that I didn’t care about the past and wasn’t tied to it. When I had a chance to create a research center from scratch, I decided I would meet with my first three PhD hires and ask them what the bottlenecks had been. First, all science is called small science. You get an idea for secret sauce, go to NIH for money, build your team, then I might take it away from you. I decided that instead of creating divas, I’d create a ensemble of people who could work with each other.
Also, I decided that all information would be stored together instead of on individual PCs. So, we had terabytes of data to study, but had to build from scratch data mining. I hired a Penn bioinformatics director, hired 10 people, and worked with dozens of companies to come up with trademarked capabilities. Researchers in our institute can query all 40,000 ladies in our database. How many of you drank coffee? How much coffee? Then, you can do an analysis of which ones got breast cancer. This was set up in a manner so that not all donated serum and blood and tumors were cancerous. Interesting. Maybe those who drank the most coffee don’t have breast cancer. It creates a way to query issues that could be pertinent to disease states. It was not disease-specific. It can apply to any disease.
I found that PhDs don’t talk to MDs. I hired some MDs and got teleconferencing to meet weekly with oncologists and pathologists from the Army about problems with individual patients. We took those back to the bench to find solutions. That’s translational medicine. We’re way out ahead of everybody’s headlights, and for those mired in the traditional system, they’re not only afraid but desperate victims because it changes the way they get funding.
To communicate information back and forth to the Army, we have a network of OC-48 capable dark fiber. We can transfer entire hard drives in seconds. In Windber, PA, a town of 4,200 people, we have some interesting opportunities. The space and missile defense command that had the original Star Wars defense program had a civilian who put together a team of $7 billion worth of research to fuse infrared and radar together to detect missiles from outer space. His sister died of breast cancer. He vowed to have those algorithms declassified for us to fuse ultrasound and digital mammography. GE is a partner doing research with us. We have three MRIs with breast-scanning capabilities doing fusion of technologies to find better ways to avoid misdiagnosis. All in a little 50-bed hospital two hours from Pittsburgh. It’s a fascinating evolution that came from the mind of a band director. [laughs]
Describe the hospital’s IT systems and their role in your strategic plan.
Because of the system that we’ve put together, we have interest from all over the world, except in the US. Go to the Netherlands, there are eight academic medical centers cooperating, but they didn’t have tools to mine the data to make it translational. We’ve been back and forth for a year working on software we created here to mine that data.
We get breast cancer tissue donations. We can do a genetic analysis in-house to determine which genes contributed to it. Then, we have the capability of determining which proteins were contributors to spreading the disease. Both of those modalities create huge quantities of data. Then, we do histopathology and molecular research, clinical and diagnostic data. We have mountains of data. One piece of equipment can create six months of data to research. We can see the potential impact of alcohol or obesity. We think it will contribute substantially to future cures as we analyze the data.
On the downside, we’re way out ahead of the headlights. We’ve spent millions trying to get software companies to cooperate with each other and designers. In one meeting, we had six companies involved in the data collection process. We had to put them in a room and lock them in until they agreed. Everybody was afraid to let their secret out. One large company that I’ll leave nameless – they can mine huge quantity of data for retail and banks, but in biology, they walked away and said, “We can’t and won’t do it becuase something that’s brown 1000 times turns green. It just happens.” They had no way to turn their analytical tools into biological analytical tools to meet our needs.. Another company asked for a meeting and in the NDA said, “Anything you say that we can remember, we can use.” [laughs]
How important is IT overall to a hospital’s success and to patient outcomes?
We just put out another $3 million for Meditech.
Concentia Digital of Columbia, Maryland … Duane Shugars is president, a young guy. His company was hired by National Geographic to digitally catalog all their images and films. If you want a picture of a lion with a bird on its nose, you can search for it on the Web and buy it on the Web. Then the NFL contracted with them to catalog and organize plays, so when they said, “Here are Terry Bradshaw’s top plays”, they can find them. Then the CIA and FBI hired them. They came to us through an acquaintance. Everything we do is digitized and put into their repository. With 40,000 samples, a single pathologist has done an analysis. He’s a research pathologist instead of a clinical pathologist, so instead of 20 things, he looks at 120. Theoretically, any scientist anywhere in the world looking for samples can be search and those samples would come to them visually.
They say politicians can have national influence, but they still have to be re-elected by the folks back home. Windber has a lot of national publicity, but you’ve said locals don’t really know much about the hospital. How can you bring the national message back home where it can do some good?
In 1977, we had the second Johnstown Flood. We had the largest out-migration of any urban area in the US except East St. Louis, Missouri. Our demographics look like Dade County, Florida. We have large quantities of octogenarians. The average person has lived in their home for 38 years. The hospital went through a tough decade in 60s and 70s. If they have a bad experience, they don’t easily forget it.
Our publicity has been in Forbes, Fortune, Wall Street Journal, CNN, the Today Show. That’s not where they live. It’s been a 10-year uphill battle to get our locals to realize that this is a unique place. The national infection rate is 9% in a hospital. Ours has been below 1% for almost nine years. So, how do you put billboards up and say, “Come to Windber and you’ll die less”? [laughs] It’s a challenge that doesn’t make for happy competitors.
We’re starting to get local recognition, but it’s happened because of my blogs. The former public relations director of the Pittsburgh Symphony, now 81 years old, said, “Why aren’t you blogging?” I wrote my first blog in May 2005, having no idea that I was the only hospital CEO with a hospital-endorsed blog in the country. The local paper asked me to write op-eds about healthcare. Another little paper asked me to write a comedy column and I became a local folk personality, the baby boomer with the child problems. Then, there were other blogs. The bad news is that none of them pay, but we’re getting the word out. When I was in the Netherlands, they said, “We love your blog.” [laughs]
Tell me about the Planetree system.
Angela Thieriot had to have surgery in the 1970s. She went into a San Francisco hospital and had the typical hospital experience, like being a lab rat. You’re a number and an organ and it’s cold and detached and there are heavy duty rules based on the military system of triage. She came out of it wrecked that American healthcare was so insensitive and cold.
She convinced the hospital to give her a wing to design care that doesn’t require leaving your dignity by the door. A hospital in Oregon tried it and was interviewed on Bill Moyer’s “Healing and the Mind.’ She became a folk hero in a little 50-bed hospital. The movement started to get traction. It did well for eight or so years, then died. A hospital in Connecticut bought the franchise rights and I was the third hospital in the US to become a Planetree hospital.
I’ve been on their board for four years. We’re pushing 160 hospitals worldwide. It’s catching on as Baby Boomers become patients. They’re not happy with instant Sanka in a pack. They will want a decaf latte with skim milk. It’s the best of a hotel, hospital, and spa. Patient empowerment and patient care. Care isn’t centered on physician times and dates or employee’s availability. It’s based on centering care around the patient. Every patient in our hospital is touched multiple times every day by caregivers other than RNs and MDs. We provide beds for loved ones, kitchens, showers, and beds in the OB suite.
The greatest compliment was when surveyors from state were here two years ago and couldn’t fund anything wrong. The surveyor said she wasn’t from around here and it was the 35th hospital she’d been in this year, but told her husband that if anything happened to her anywhere, no matter what, bring her here.
I’m 60 years old and have six heart stents and my mission is to change the way healthcare is delivered. I’m saddened by how science works and how hospitals don’t cross the line of taking care of souls and not bodies
Can the hospital succeed as an independent and can anybody compete with UPMC in western Pennsylvania?
I don’t know. If we had not made the choice made by our board, there would not be a community hospital here. Was either decision a good one for the community? The board chose to take this on and try to compete. We only represent 6% of the healthcare in this region. It’s not like we can put them out of business. On any given day, if you say “Go Penn State” or “Go Pitt”, you’ll make half the people in the room mad. It’s not just an UPMC juggernaut, it’s also a Geisinger juggernaut.
Three, four or five years from now, will Conemaugh survive? UPMC has already made a run on this area and it didn’t go the way they hoped, but they have their joint ventures and insurance here. It remains to be seen if Geisinger comes in. We can survive only if we put all the pieces of the puzzle together. Oprah drops off her dog at a spa 20 minutes from here. If I can get her in here and beat that 30% error rate … I think the answer is yes, we can survive, but that’s an uphill challenge.
You mentioned in discussing Michael Moore’s Sicko that we’ve never had a health policy in this country. Why do we need one and what will it take?
I’m not a policy wonk and I was out front in rejecting Hillary’s last plan. It doesn’t do any of us well to have what England or Canada has. The waiting time is years. People come across the border from Canada for heart surgery. I’m not sure that plan is the best way to go.
Internationally, we’re through the roof, #1 in cost and #42 in quality of health. I’ve seen a lot of diagnostics that relate to typical overhead. With a private insurance company, it’s 20%. With Medicare, 3%. There’s got to be something in between that makes this work. UPMC is positioning themselves to be a global player in single payer. Highmark is doing that. Does that look like Medicare or a modified insurance system?
I can be the least expensive hospital in the US and it doesn’t matter because the insurance company doesn’t have to pass it on to the consumer. We have to find a solution that doesn’t permit this outrageous 47 million people to be uninsured. That’s unconscionable. Some kind of single payer has to evolve or it will become a worse and worse train wreck.
You’re speaking at a blogging conference this month. What’s your message going to be?
So many of my peers are finance guys who stick their heads in the sand and go with business as usual. It’s kept us locked in the industrial revolution. I’m doing a podcast next Friday with someone from Mayo. Transparency will be huge. Communication through the Internet is huge. We’re more connected than we’ve ever been in history. A political leader who could lie to his people is being checked internationally by hundreds of young people. We’re finally totally linked.
I wrote a blog that I thought the demise of Imus was because of that. It wasn’t that he hadn’t said something like that 1000 times before, but everybody grabbed onto it and made something out of it. Get with it and figure it out. It’s the new world order. New tools will reach out to people in a different way that will make or break your business.
If you weren’t CEO at Windber, what job would you want?
If I’d been talented eough, a top level orchestra director. It’s the most rewarding thing I’ve ever done. Touching people’s lives like this is important, though. At this stage of my life, I’d just like to speak and write to change healthcare. I love getting the message out and shaking up the status quo. It’s not my system, it’s an old system that needs re-evaluated. Some day I’m going to write a book at how being a high school band director is like being a hospital administrator. It really is.
Readers asked me during the HIMSS conference to check out Pensacola, FL-based Cogon Systems, Inc. I was vaguely aware that the company was doing some Florida RHIO work, but that was all I knew about them. HIStalk readers are talented at sniffing out up-and-comers that have the potential to be disruptive, so naturally I was up for learning more, even though I never did arrange a HIMSS rendezvous.
President and CEO Huy Nguyen was agreeable for a chat when I e-mailed recently. I appreciate his taking the time to give me some background on the company and to peek inside the mind of a Navy doctor turned entrepreneur, which I found fascinating.
First, help me pronounce your name and that of the company. Is it Hyoo NWEE-un?
Yes, and the company is pronounced COE-gun.
Tell me about yourself and Cogon Systems.
I’m a physician by training and I still practice part-time in the emergency environment. I like it because, at the end of the day, what we do in healthcare as well as in business has to translate to better patient care. It’s nice to continue to focus at a very trench level on what the end game is about.
I was a Navy physician. I became immersed in HIT because growing up as a military doctor meant cutting my teeth on an EHR. I always assumed that the market had systems as robust as the military’s systems.
Being an attending physician in the Navy, I was taught that, if you want lab results, you don’t go to the chart. You go to the computer and look it up. You certainly don’t query someone else to look up your data. Sometimes a doctor’s idea of an information system is to ask a nurse or clerk to bring up the information. In a naval career, you couldn’t ask that nurse because she might be a commander and you might be a lowly lieutenant. You knew better than to use her as an interface to your information system.
The Navy, early on, was an early adopter of new technology. One of the things it adopted early on was PDAs. In the early Palm and Handspring days, we bought into it hook, line, and sinker. At Naval Hospital Pensacola, the commander bought all the doctors PDAs. With your taxpayer dollars, I became enamored with the idea of mobile healthcare.
Those were glorified toys at that time. You stored everybody’s beeper and your calendar. That planted the seed in my mind – wait a minute, should this be an interface to the clinical data, just like the desktop was to the military’s CHCS clinical system?
I broached the idea of a mobile interface to clinical data with a friend of mine named David Hsu. We built a prototype and took it to the military. In typical bureaucratic fashion, they asked, “Aren’t you a doctor? Why are you building prototypes in your off hours?” They didn’t allow us to take it to the next step.
David and the engineers took it to Sacred Heart Hospital in Pensacola. This was in the pre-HIPAA era. Today, they’d laugh you out the door for asking for access to live data to build a system. They thought it was great that young engineers and I were interested.
The engineers took a prototype and brought it to production level. Once they had a working product, it was up to me to decide about my involvement with the venture. The guys approached me about running the thing, even though I didn’t come from a business background.
My wife and I thought about it. The military sent me off to Iraq in 2003 in ground support for the Iraq war. There’s nothing like war to make you a risk-taking entrepreneur. After seeing the fighting, I told my wife, “Heck, let’s go for it.”
I left the Navy in 2003 and took Cogon to the marketplace. At that time, we were mostly focused on mobile technology. We had to learn to integrate back-end healthcare systems, focusing on clinical systems. We became adept on variants and flavors of HL7. To stage the data to our mobile platform, we created a CDR.
We had a bunch of guys so focused on the mobile interface that they didn’t realize they were creating a robust back-end world. As we grew, we realized that the value isn’t moving clinical lab results or exposing them to front-end PDAs. The potential value is all the back-end stuff we did and the ability to integrate it into a comprehensive CDR.
I started to realize the true value of what we did. What about the possibility of integrating data from multiple providers? We became early thought leaders in Florida on health information exchanges. We grew our technology and moved way from an enterprise level platform to a Web-based platform.
We have a contract in South Florida and have integrated eight clinics, Mercy Hospital, and soon Jackson Memorial. We take data in HL7 or CCR formats and store those data in separate accounts. Once they’re in those repositories, we have a record adapter service.
We have a service-oriented architecture. We’re able to take data and adapt it to CCR and then move data within our own platform. Our Web portal is almost treated like a third party application. We don’t care which application we’re working with.
In the past four years, we’ve taken a mobile enterprise play and migrated to back-end clinical data integration and now have gone completely Web-based with it. We’re keen on SOA and standards like CCR. Hopefully, we can create a Web-based milieu and can launch potential other partners off that platform.
We’re not a RHIO company. We don’t send sales guys out to find RHIOs. Interoperability, especially with ONCHIT, is too much about RHIOs. A community is defined in different ways.
How is the Moment of Care product different than the usual physician portal?
It’s unique because it has the ability to give the end user control. In Miami, we have funding to establish information sharing between military and civilian providers. The portal can pull disparate records into a cumulative view. It also allows a provider to titrate how much data he wants to view.
Let’s say we have robust RHIO and a Nationwide Health Information Network. Let’s say the user can turn on the fire hose and we can bring in that patient’s clinical data, local and from all around the country. You’ll have to comb through that to make an assessment and plan. We drive our end users to an encounter-level screen to show what they’re interested in – a visit or a lab visit. We bring in the in-depth clinical data from only those encounters. So, what’s unique is the ability to leverage the Internet and control what the user wants to see.
Some would say that physician portals are obsolete in an era of interoperability, where information should be placed directly into EMR systems instead of just being read-only for those who go out looking for it. Do you agree?
I agree. It’s our plan as part of our continuing development. HIS is moving so fast that you always have to stay ahead of the curve.
I’m in complete agreement. I’d love to get to the point when the only people who look at our portal are those without EHRs. We serve as a true data hub. We take data from our trading partners and parse out data based on defined rules to entities that are authorized to take the data from us, consume it, and transiently display it in their own system – electronic health records, disease management, pay for performance, whatever. We would then supply data to those applications.
Once you create a good interoperable platform, it’s not just the Cogon portal. They key is to create a milieu that can grow a wide variety of value-added applications.
As a small company, how can you market and sell your product?
We think of ourselves as a healthcare interoperability solutions partner. One of the things we do that allows us to compete in our regional markets of focus is that we look at ourselves as a partnership. We have a cost-effective application platform that allows people to integrate into the exchange and from there. We are keen in almost liberating the data in a secure manner.
We’re pretty flexible, being privately held, on the best business model that fits a particular community. Is our platform a shrink-wrapped package? Yes, but what are we going to do with it and what’s the endgame? We spend time helping client figure that out. We don’t go into a relationship and say “This is what our package does.”
In South Florida, that community and the folks involved in that RHIO were very forward-thinking. Think of your major metro areas. I don’t think there’s a consensus yet or even close on sharing health information. Miami is quickly coalescing around this. We were fortunate to be early thought leaders. From the get-go, the RHIO has always gotten a sense that we were more than a technology vendor, we were a partner in the deal. As long as I’m running the company, that sense of customer relations will be part of our way of doing business.
A lot of companies are committed to the RHIO vision. Some of their commitment is not straightforward. Others are committed, but don’t have the wherewithal to get the job done.
Earlier versions of the company’s web page list a co-founder and several other executives. Has the management team changed?
Companies, certainly entrepreneur efforts, go though phases of development. The first phase is all about the vision, the conceptual idea and the visionary leader’s hopes and dreams. It was mobile technology in healthcare.
Then, you go to the prototype phase, where you get something to work. Then, the initial market phase, where you have no clue what the market wants, but you think you can teach it what it wants. That’s completely ineffective.
At some point, you go through a process phase, where you realize your prototype isn’t scalable to production level, and the market is telling us our true value is elsewhere. In our case, the market was telling us our mobile technology was gee-whizzy, but it was our integration they wanted.
Then, you reach production. You’re not prototyping any more. You’re delivering the product plan.
Then, you reach nirvana – churning it out, being good partners, delivering on a tight timeframe. Execution is incredibly important.
We have undergone personnel changes as we entered the different phases. As a physician, I realized that it’s great to have clinical knowledge and insights, but at the end of the day, if I wanted to keep running the company, I had to evolve. Vision is great, but execution is better. Was I a manager or a doctor who happened to run a software company? My job is to be a great manager. I have evolved and changed personnel to evolve. The processes for prototyping to delivering widgets is a totally different mindset and sense of purpose.
From the perspective of both headcount and the bottom line, we’ve grown nicely. My #1 growth need is good people who want to work in a culture of quantifiable accountability. This is a company where we are very metric-driven. It’s transparent and achievers are rewarded. I’m looking for developers and sales and business development people.
When I Google Cogon Systems, I get an ad for Patientkeeper. Is that surprising?
That does surprise me, but I think people still think of us as a mobile technology play. A lot of us have realized that mobile technology itself is not a sustainable model. We started to make the move away from being a pure mobile technology play in about a year and a half.
Managers don’t bury their heads in the sand. If you’re a good manager, you read what the market is saying, not what you hope the market is saying. For a lot of us purely focused on mobile technology, too many people hung in there thinking it was going to be rampant when that’s not what the market was seeing.
We haven’t given up on mobile technology. We have a project with the Army on mobile technology on our common Web-based platform, so we’ll continue to drive the possibility of mobile technology of healthcare. You just can’t base your whole business model on it.
The iPhone is just the beginning. This is the second or third inning in mobile technology. In healthcare, we’re in the first inning. It has a very promising future in healthcare and we’re interested in driving value-added solutions from our health interoperability platform.
You were a Navy physician before starting the company. What do you like and dislike about being an entrepreneur?
I dislike, as is typical as someone from a physician background, that things never happen as fast as I’d like to see them happen. The great thing about medicine is that there’s always a conclusion at the end of the day. In business, I learn every day to be patient.
Like South Florida. The people who audit the project would say it’s impressive what we did, indexing live data in six months and in production use. For a lot of people, that would be a fairly rapid implementation. Six months for a doctor is still a long time. Sometimes I find that frustrating.
I’m frustrated both as a doctor and as someone on the technology business side that we’re not as sophisticated as other sectors, like retail and banking. I see much greater interoperability and the power of the Internet. I’m involved in healthcare as a provider and as a technology provider, and at times it hurts me that we’re dealing with people’s health, more important than banking accounts, and we’re not as sophisticated.
What’s exhilarating is that drive for greater performance. If you’re a good company, it takes on a new life of its own and it’s greater than any individual component. If I’m not the best manager, Cogon will replace me. The challenge is on me to keep up with the growth of the company.
That drive always to be bigger, better, more profitable … it’s never enough. You can go talk to the CEO of GE and he’s in the same boat. You can make 10,000 times Cogon Systems, but he and I still share the same fundamental drive – how can I be better and bigger tomorrow?
Executing as a team. Medicine is an individualistic endeavor. If you come into my ER unresponsive, I’m not going to survey my team and ask if should start CPR or intubate you. I’m going to tell people what needs to be done and we’re going to get to it. It’s exhilarating motivating people toward a common goal and delivering it. That’s the most rewarding aspect of business. We’re at the stage of execution and we have an advanced platform, but at the end of the day, what are we going to do with it for a particular client, on time, as promised, and as defined by cost.
What’s the five-year plan for the company?
I’d like for us to be the leader in healthcare interoperability solutions at either a hospital level or even a community level. I’d like for us to be extremely competitive in using the best of the Internet age and the best of creating an interoperable world.
Just as importantly, we’re looking at creative business models to facilitate people getting into this interoperable world, with minimal cost to get on board to trade data as a community. Creating an environment where we have a lot of partners that can drive solutions off that platform, with a whole host of companies that use our platform to create disease management modules or take our data and present it inside their EHRs and facilitate better patient care.
Finally, as a physician, my hope is in five years that our technology has very direct implication on patient care and a more sophisticated, empowered consumer.
What healthcare IT people and companies do you admire?
I particularly admire GE across the board. I think GE always has that drive to be bigger and better. If you’re in this business, your goal is how to serve the market better. They have a diverse portfolio and their ability to manage that diversity is incredibly impressive to me.
What could we do better as an industry?
I would like to see a greater level of consensus and collaboration of emerging standards or a drive toward an interoperable world. We still have a tendency to think about “our solutions, our clients, our turf”. I’d like to see us make greater inroads to lead the charge to facilitating patient care with an interoperable stance. I’m glad the government is leading the charge, but we have to decide if we’re a market or a government endeavor. I’m a proponent of healthcare as a market and I’d like to see the market take the lead in driving the issue of interoperability.
As a doctor and someone in business, what are your thoughts about the role of HIS in healthcare as a whole?
We ought to be clear to the healthcare market and the country and political leaders. There’s a lot of inefficiency and we know it. But, information technology is not the panacea to the underlying healthcare issues.
As a doctor, one thing that always concerns me practicing in the emergency environment is, “Does the patient have access to care and can they afford care? Can they afford a $100 antibiotic, do they have insurance?” No matter how good our common dream of an interoperable world, it doesn’t solve the basic problem of whether that patient can afford the antibiotic.
When I see during the selection cycle using health information technology as a possible panacea, I think it diverts people from some basic underlying issues. Is it a right or a privilege? If it’s a right, how do we pay for it? If it’s a privilege, how do we help people who can’t pay for it? If we’re thinking about HIS as a means to improve cost containment, that’s one thing, but if you’re focused on that as a way to solve the overall problem, you’re being completely disingenuous or naïve.
A long-time reader whose background is clinical suggested I talk to the folks at Meru Networks. I figured it takes a lot to get a clinician excited about IT nuts-and-bolts stuff, so I was happy that Ken Creager, senior director of strategic markets for Meru, agreed to chat. I hear gripes regularly about wireless networks, even with the relatively modest demands placed on them. I was interested to learn more about what’s changed in the time since many hospitals put up their first 802.11b network. Thanks to Ken for the conversation.
Tell me about Meru Networks.
Meru has been in business since 2002. We produce a family of access points and controllers for mission-critical and life-critical environments. The company is headquartered in Sunnyvale, California, with operations in all of North America, Europe, Asia, and R&D in Bangalore, India. We’re not public so we don’t provide financial numbers, but we’re about 280 people, growing at a very rapid pace due to a lot of industry demand. We’re having a great time trying to respond to the needs and requirements of the field.
The lion’s share of our business is in the healthcare and education markets. In healthcare, we solve unique problems as a result of doing a lot of observation in the marketplace, getting assistance from people, and from our participation in HIMSS. We don’t always go in and talk to the technical people.
We look at the nurse as the integrator. If the technology is going to work, it has to be easy to use and functional to a nurse. If a nurse is using a PDA at the bedside, that person doesn’t really care if it’s the applicaton, the unit, or the wireless network if it fails. We work closely with our clients and our partners to make sure we’re very functional for the clinical staff in hospitals.
What’s the penetration of wireless networks in hospitals and how are they being used?
The actual penetration is close to 80%, but let’s clarify. Many of those deployments are first- or second-generation, with fat access points that are difficult to configure and lots of cost. They also tended to have been installed for a single application or department, like something radiology or oncology wanted to put in. It wasn’t pervasive until recently. Most hospitals report that they have some use of wireless, but it’s not pervasive.
What we see happening is an absolute explosion of applications. Go to HIMSS or trade shows and you’ll see applications and devices using wireless as a transport. There was a time when wireless was nice to have, like in the conference room. Today, it’s an integral part of the architecture and an enabler for taking care delivery to the bedside.
We spent a lot of time looking in hospitals and saw this snowball of applications coming at clinicians, but found that networks aren’t pervasive or are limited in their capacity and are failing. Those first implementations may have worked well for an application or two, but with 15 or 20, they are failing. Adoption of devices is not being as well-received as it could have been with a more robust network.
That has given us a window of opportunity to come in and show how our technology is differentiated in the marketplace. We have better coverage and performance and can prioritize traffic to assure application delivery. Let’s say we have a Wi-Fi based phone and we want to make sure that calls get through ahead of someone in the back room who’s Web surfing. We can inspect that traffic, prioritize it, and makes sure it gets through. We have quality of service built into both the upstream and downstream.
A great application of pervasive wireless that we have witnessed first-hand are nurse-type devices like Wi-Fi based phones or Vocera-type badges. You see clinicians walking the hall with those devices. We noticed they stopped walking. They told us it was because they had a good signal and stopped so they wouldn’t lose it. We’re in the mobility business and we asked whether that makes sense. We’ve seen areas where good coverage was marked on the floor with tape. That’s the pervasive element. Is if through the entire facility? Not yet today. We’re getting there.
Common problems in hospitals include dead zones, slowness, and overloaded access points. How does your technology address those problems?
Wireless runs on a series of channels, usually 1, 6, and 11. Access points have different channels and you roam between them, much like when you’re on the cell phone in your car. That inherently causes problems in your end device because it has to continually look to figure out which one of these guys it wants to talk to. At some point, it’s talking to two of them and has to decide how to hand off.
RF planning is required to determine how access points in a general area interfere with each other. Also, as devices move, they have to decide which way to go. If I’m trying to talk to two different access points to determine which is stronger, that’s taking time on the network. Our advantage is that we can put all our access points on a single channel. The end user device sees it as one big network.
There’s no handoff. We make that decision for the end device in our controller. If you’re walking between 15 access points, that entire campus may be on one channel and you’ll never know it’s happening. The advantage is a four to five times performance increase because you’re not asking questions where to go next. Also, it’s seamless between access points. The opportunity to drop a call or device is almost completely negated.
If you think about what’s happening with clinicians walking down the hallway and looking at vital signs on the laptop and they hit a dead zone, they’ve lost information. We take that away because our coverage is more pervasive. We have quality of service upstream and downstream and we guarantee delivery of those packets for critical devices like a patient monitor or voice call. We can assure the delivery of that piece of information.
This all plays into clinical adoption. We’ve seen the reports come out. In the 100 Most Wired, technology today is having a positive impact on health, safety, security, and mortality rates. Much of that’s due to the deployment of technology solving errors at the bedside, medical conflicts, wrong medications, those kinds of things.
Another key thing we find in hospitals is that they’re amass in assets – wheelchairs, infusion devices, phones. The biggest question is “where are they?” COWS and crash carts move to emergency situations, congregate around nursing stations, and then get pushed into the hallway. We can do some locationing with our management software that lets you determine where those devices are.
Because we’re able to do a single-channel architecture of the standard 12 channels, that gives you 11 available. You can stack channels like a stack of pancakes. You can segment your traffic. As an example, you could put voice traffic on Channel 1, data on Channel 6, and telemetry on Channel 11. That increases your capacity on the network and segments them. They can still talk to each other.
Because we don’t have channel conflicts, when you need more coverage or bandwidth, you don’t need more RF planning. You plug in a new access point, it figures out what’s around it, and it becomes part of the community. That’s a low cost of ownership.
Hospitals spend as much upfront with our competitors doing surveys and channel planning as they do on the actual product. We can almost eliminate that. You don’t need as many of our access points to get the same or better coverage as our competitors. The cost of an access point may be equivalent, but you don’t need as many.
When you look at a clinical environment and recognize that a critical care nurse will take 1,000 data points in a shift and there’s five or six of them trying to do something and they congregate, do they have the bandwidth to get their job done? As they move out on the floors, do they have the quality of connection to get their job done?
Also different is that we have an ability to create fairness in the networks. That offers us the ability to do backwards compatibility. You have the b-rated radios that operate at 11 megabits per second. The g-rated ones are at 54 megabits per second. If a guy comes in to your g-network area with a b device, everybody goes down the lowest common denominator. Everybody gets slowed down because of that guy.
We can give all users their full capacity at the same time. We can offer 802.11n megabits, but still allow g and b clients to work on the same network together. In many industries, but especially true in healthcare, devices stay in service for many years. They’re not going to rip out technology to replace the radio cards. That gives us an extensible architecture and investment protection for existing clients.
Describe 802.11n and what impact it will have on healthcare.
It’s the next generation of speed. It will give you six fold the bandwidth of 802.11g. There’s a lot of technical stuff around that, but from an end user perspective, you’re bringing true desktop wired speed to the wireless world.
Most connections to the desktop are 100 megabits. You’re going to have wireless signals that are three times as fast. If you’re building a new facility, do you need to put those wires in place? You can go to the all-wireless enterprise and have speeds faster than that of the wired world.
In healthcare, most of the devices we see are operating very well at b- and g-rated speeds. Ascom has a great g-rated phone purpose built for healthcare with messaging and made for clinicians. On your hip, the display is upside down so you can read it without using your hands. The next generation of phones will have n-rated radios, so you can have more of them out there.
The biggest impact will be in imaging and video. Today’s early generation networks don’t have the capability to take full-motion video or large images. In a shared PACS environment, you might need to look at large images in real time. 802.11 n will allow you to do that.
How important is wireless voice over IP to hospitals?
We’re seeing it as becoming a much bigger element. They view the network as being able to carry everything. We’re seeing dual-mode phones – cellular outside, Wi-Fi based inside. Doctors look like they have Batman utility belts with 15 pagers and devices. You will continue to see an explosive rate of devices coming down and then a convergence period. Blackberry is coming out with a dual-mode device.
Voice is becoming a much bigger element of these networks in healthcare. In many cases, it’s the driver for upgrades. Then, you get into, “What’s the quality of the call? Is it comparable to toll grade? If a bunch of users make calls, is the network degraded?” We have technology that protects the quality of those calls.
What patient care quality issues can result from ineffective wireless architecture?
Time. Let me go back to the nursing station to see what’s happening. If an application is readily available on a tablet PC, laptop, phone, or multi-use device, you’ll save time. The opportunity for errors is reduced. Where you find a low adoption rate of handheld devices and point of care by clinicians, you find higher error rates. Those have an impact on care delivery and quality of care.
If I’m a hospital CIO, why shouldn’t I just buy Cisco like I’ve always been doing?
Cisco has a great product. I used to work for them myself. But this technology is truly differentiated. When you look at a Cisco product, you have no single product in the top five. You’re not really getting best-of-breed in any segment.
We use Cisco products in our demos. We can make their wireless phones work better than they can because our wireless network is so robust. Our technology is extensible and backward-compatible. There are no forklift upgrades. Once you’re set up, you just stick an access point in the ceiling.
CIOs have multiple vendors and multiple levels of code. With us, you have one level of code that runs all controllers and access points. The controller code is broadcast out the access points. You set a corporate policy for HIPAA or JCAHO or whatever is required. Let’s say you allow a certain number of guests, but you have to keep them away from the business office and lab. You set those central policies and the access points come online, assume those rules, and apply them universally across the network however you’ve set it up. Once you’ve set it up, you don’t have to do it again.
We can also suppress rogue access points. Somebody runs down to Best Buy and buys a D-Link box and plugs it into the wall. Suddenly you have a new wireless hotspot with no security policies applied to it. Somebody in the parking lot has access to your network. We have rogue detection. We determine it’s there and don’t let that person come in. We go one step further. Once we recognize that the access point is there and it starts to broadcast, we jam the signal. That keeps devices from taking time away polling the access point. I see that guy broadcasting, I’m going to jam the signal so the end devices never see it and can’t take up bandwidth.
How do you justify the cost of your technology to a hospital that already has a wireless network?
Does your existing wireless network have the capacity to deal with what’s coming? Most tell us no. People with a network in place for 18 to 24 months are having to replace it because of the applications coming. They have to put in an extensible one for the next speed or the technology required.
The advantage we have is that most have already come to the decision that something has to change. We come in and say, “We can solve a lot of these problems with coverage and speed and ROI and save you money as compared to the other vendors, and provide you a better of quality of service.” Our value proposition is strong. Clients are feeling the pain by finding low adoption rate by clinicians on new devices. The end user doesn’t know what’s behind it, it just doesn’t work. We try to build the most robust infrastructure at the lowest cost to make sure those applications work.
Cisco convinced HIMSS to create The Community for Connected Health, which seems to be a thinly disguised Cisco trade group that paid HIMSS for exclusive access to its members. Does that make it even harder to complete against the Goliath?
What’s interesting about that … they did that with HIMSS and had tried to do the same thing with the AMA, who pushed back and made Cisco take down some of their marketing. A week later, Cisco announced their endorsement by AHA. Everyone I’ve talked to on the client side and vendor side says this is an abuse of .org facilities and people. The industry is policing that themselves.
I’ve instructed my team to not even respond to those questions because it’s how Cisco markets today, defensively and protecting their ground. Frankly, I’ve talked to folks like yourself who view that as very offensive, “Cisco has infiltrated HIMSS and I can’t believe HIMSS any more.” I think the industry will self-police that. People who have drunk the Cisco Kool-Aid will buy it no matter what. For those wanting a best-in-class solution, I don’t think them doing that with HIMSS or AHA will influence them in making a purchasing decision.
Wi-Fi companies seem to have had mixed IPO success. Meru was considering IPO this year. What’s the most likely outcome?
We are going through a rapid growth spurt. We just tripled the size of our sales team. There have been some successful IPOs, some not so good, some consolidation. The opportunity for us to move forward and grow this company is excellent. There’s a lot of opportunity out there. We have a disruptive technology. I’m sure the company and its founders and its venture funding would like to see us go out. I’m not privy on whether it’s this year or next or whenever, but when it’s time and the market dynamics are correct, I’m sure we will go out.
Any final thoughts?
Our wireless technology is unique. We’re fully standards-based and we help drive a lot of those standards. We’re innovative in our technology. You’ll find that many if not all of our customers are raving fans of what we do. We have very large hospitals like University of Miami, Wake Forest, and St. Johns. We continue to add and grow in this market almost on a daily basis.
We’re something of a positive disruption. We’re getting a lot of positive write-ups and are getting attacked by people you’ve mentioned [laughs]. When we’ve reached the point we’re being attacked by Cisco, that means we’re a thorn in their side and are disrupting their business. That’s good thing.
The challenge is getting the word out. We’re a small company compared to Cisco. We only do wireless. Customers are benefiting financially. I’m happy with where we’re doing. We’re focusing not only on the IT buyer, but how the products are used by the clinical staff. As we well know, doctors walk in with a great application they found or something they use that they want you to support. We’ll see more and more of that. Having a network that is extensible and easy to add capacity to will have an amazing capacity on the IT staff of hospitals and the budget.
