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HIStalk Interviews Mike “The PACSman” Cannavo

October 1, 2014 Interviews 4 Comments

Mike Cannavo, aka “The PACSMan,” is founder and president of Image Management Consultants.

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You recently spent time working for a major vendor after years of solo consulting, but now you’re back on your own again. What was it like on the dark side?

I was always curious on what it would be like to work for a vendor again, but I didn’t want a job that required me to be away from my kids while they were growing up. My father worked three jobs during my own youth and I really didn’t get to know him until after my mom passed away in my mid-30s. As tempting as some of the offers I had from major companies were, I swore there would not be another “Cat’s in the Cradle” scenario in my own life, so I chose instead to balance my own work life with fatherhood. My youngest son graduated high school in May 2011 and I accepted a position with a major vendor in July 2011.

The market had changed a lot since I last had a real job with a steady paycheck. Some things, like corporate politics, remained the same. I stuck it out almost 2.5 years until I looked in the mirror, didn’t like what I saw, and then played Roberto Duran and finally said “No Mas.” Besides, I had at least 50 bets out there that I wouldn’t last more than two days in a big company setting.

On the positive side, I learned the value of service, how important having a good project manager really is, why managing expectations is key, why you need to get everything in writing, and the importance of a strong IT department. On the minus side, I learned that simply doing your job often isn’t enough. The blame game is alive and well and people often rise to the level of their incompetence.

 

How has PACS changed in the last four years since we last spoke in an interview?

PACs is no longer an independent system, but is instead looked at as a crucial part of the EHR. Vendor neutral archives, once considered a central data repository for radiology images only, have been expanded out to included cardiology, medical records, and numerous other ‘ologies. Large healthcare systems are either planning or implementing the sharing of images and images locally as well, both on a regional and even national basis with establishment of HIEs. Interestingly, private HIEs are growing at the rate of three to one over public ones, with over one-third of all hospitals and about 10 percent of all private practices sharing data.

We still have a very long way to go, but as we both know, all progress in healthcare is slow.

 

You mentioned in an article I read that the PACS sales process has changed as well.

For all intents and purposes, large-scale capital doesn’t exist. What little does exist is being used to replace things that should have been replaced years ago. The name of the game is finding ways to implement new technologies by either offsetting costs from operating budget or showing a return on investment out of the box by obtaining either increased reimbursement or decreased costs.

As controversial and possibly upsetting as this statement might be, improving patient care, while important, can’t be done at increased cost. You have to somehow show an ROI for the facility or it’s usually a no-go.

Healthcare profits are getting eaten alive by the need to implement federally mandated programs, from MU to shoring up internal security. Nearly all of these involve IT departments that have their own staffing and budget cuts to deal with.

What’s funny in a not so funny way is that MU encourages hospitals to share data with a laundry list of people, yet it also needs to be secure enough that no unauthorized access happens lest you incur a $10,000 per event HIPAA penalty. Look at the Community Health Systems breach. This will cost them a fortune if the feds don’t take into account they did all they could from a security standpoint, assuming they really did do all they could to prevent the breach. This will take years to sort out, all the while with the organization having the sword of Damocles dangling over their heads.

 

What would you do differently as a health system?

Implement solutions that make sense, recognizing that many solutions don’t have to involve technology at all, but instead require workflow or process changes. I can’t begin to tell you how much trouble employing a common sense approach to problem solving has gotten me into over the years working for companies that sell technology-based solutions. Sometimes you just need to step back though and examine the problem before throwing hardware and software at it in the hope that solves the problem.

Companies typically sell products instead of solutions. End users buy products they hope provide solutions. Never the twain shall meet. End users need to be more educated before they make decisions because those decisions will last a lot longer than expected. For the most part, companies sell products and services and do not necessarily ensure that what you are buying or have already bought is what you need or is being properly used.

 

What’s the status of the PACS marketplace?

There is lots of interest in VNAs, especially those that can be used as an enterprise solution that takes images from all the ‘ologies as well as the EMR. Medical image sharing, where images are securely transferred between sites and patients as a cost-effective alternative to CDs, is also hot, especially after Nuance’s purchase of Accelarad.

Software add-ons such as radiation dose management, peer review, critical results reporting, and ED discrepancy are also hot. So are PACS dashboards, although most sites want the dashboards for free stating it’s like a speedometer in the car. For that matter. most sites want everything nearly for free, but it’s simply not going to happen. Data analysis is smoking hot right now, but finding time to review the analysis remains to be seen.

What’s not hot are upgrades for the sake of upgrading without a distinct advantage or improved feature/functionality. All the big companies want you to do this. Solutions that have anything proprietary in nature. Solutions that doesn’t interface easily with the other clinical systems in use. Anything that doesn’t show a value or ROI out of the box.

 

What about the cloud?

Depending on whose survey you believe, up to 80 percent of all hospitals have at least a few cloud-based applications running. Adoption is much slower than expected, but that is because there are so many unknowns, including security.

As was pointed out in a recent HIStalk article, running a data center isn’t the strength most providers have. Cloud providers can offer higher reliability and redundancy at a better price point than a facility maintaining its own hardware. Cost-effective high-bandwidth networks have also eliminated most of the barriers to using the cloud as well.

Once we are comfortable with the security aspect of having images and information stored in the cloud, usage should take off. Sadly, HIPAA penalties and the limits of business associate agreements in protecting the end user have made providers gun shy.

 

Has radiology embraced Meaningful Use?

With few exceptions, not at all. The vast majority of clients I am dealing with are taking a wait-and-see approach to MU before investing money due to the never-ending changes in the rules. This reflects the general population as well, where only 4 percent or so of all eligible providers have attested to Stage 2 so far.

The cost to implement MU has, in many cases, exceeded any return on investment that a group or imaging center will see. When you add the aggravation factor, you are definitely in the red.

 

What will we see in the future?

No one really knows what is going to happen with Meaningful Use, ACA, HIEs, and a whole lot more. Vendors are pulling their hair out trying to get any decisions from end users — positive or negative — while end users take the Holiday Inn approach — where the best surprise is no surprise — and choose to remain in limbo doing nothing. In the mean time, IT stands at attention waiting for something to happen so it knows what resources need to be dedicated when and where.

What is frustrating is that even if something shows a ROI right out of the box, a lot of end users are still afraid to pull the trigger. If we can’t overcome the paralysis by analysis, you are going to see a lot of companies go belly up, and soon. Add to this the market consolidation that is going to happen in the next few years with at best a few dozen companies left to provide PACS solutions and it’s a scary time, especially since all of those will need to be integrated into the EHR as well.

HIStalk Interviews Matt Scantland, Co-Founder, CoverMyMeds

September 24, 2014 Interviews 2 Comments

Matt Scantland is principal and co-founder of CoverMyMeds of Columbus, OH.

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Tell me about yourself and the company.

My partner Sam Rajan, who’s a pharmacist, and I started CoverMyMeds to address prescription abandonment. We learned about the problem when we built a prior authorization system for a health plan. 

The idea for CoverMyMeds came to us when we looked at the fact that from the perspective of a doctor, it really doesn’t matter how good the prior authorization process is for any one health plan. It’s just one of dozens that the doctor needs to navigate. The idea of CoverMyMeds was, let’s create one-stop shopping so that the doctor can use one process to submit a prior authorization for any drug to any health plan.

 

Your Inc. 5000 numbers are pretty impressive with $19 million in 2013 revenue and 73 employees. Did you plan for that or did you just happen to hit on a niche that took off?

We’ve been thrilled with how things have gone. We’re growing over 100 percent a year since we started. We’ll do about $50 million in sales this year and have about 130 employees.

I wouldn’t say it’s any genius on our part. The prior authorization process is just incredibly painful for everyone that’s involved. The doctors and also the health plans have been looking to improve this process for decades. Working for them, we were the first to be able to create an electronic process that scales.

 

It seems you would have competition from someone like Surescripts if business is that strong. Do you have competition?

Surescripts launched a product at the beginning of the year that’s a little bit different than ours. Whereas our process works for any payer, whether the payer participates electronically or not, Surescripts is launching something that works just with payers that connect to Surescripts.

So far, because the PA process has not been something that’s electronic in the past, the value proposition of our service has tended to be much stronger for the participants, where with one integration in the electronic health record or in the pharmacy dispensing system, the PA can be submitted to any payer. We also lead the industry in connecting electronically to the payers, but the process works across the board.

 

It’s a fascinating business model that drug companies to pay for the service, which they fund from the revenue of what otherwise would have been unfilled prescriptions. Nobody who uses the service pays for it. How do you get the word out to doctors and pharmacies that it’s available and it’s free?

Being free helps. [laughs] You’re right, the drug companies and now the health plans pay for our service. This is a business that has what we call network effects, which means that the more people that use it, the better it gets for everyone.

We have a huge pharmacy network. Almost every pharmacy in the country, including the big chains, uses our service. When they initiate a PA, if the doctor’s office isn’t already a user, we invite them to become a user. Over time, we’ve built that physician network to more than 100,000 distinct providers. It creates that viral process that allows us to grow quickly as a network business.

 

You’ve connected electronically to EHRs and pharmacy systems. Is that work finished?

That’s really the future of our company, but it’s pretty new. We started in the pharmacy, which is where the PA process begins today. All over the country, the first time anyone tends to think about the prior authorization is after a claim rejection in the pharmacy. 

Today, we’re integrated into almost every pharmacy in the country, right inside the pharmacy management system. We’re looking to do the same thing in the electronic health records, although that’s a new area for us.

We announced a partnership with DrFirst, where we’ll make the PA process available at the point of prescribing. We’ll also connect those pharmacies into the DrFirst system so that PAs initiated in the pharmacy can be sent to DrFirst’s doctors electronically. We’re also working with most of the other electronic health records, so I’m trying to do that same type of an arrangement. We’ve come up with a financial model where we can actually pay the EHRs to do that work. One integration is something that works across the board for every payer.

 

You offer APIs and also widgets for web pages of both health plans and manufacturers, which is pretty smart to get people to have access to your service through the other sites of the companies that you work with. How much technology is involved in what you do?

CoverMyMeds is really a software company. We don’t do any actual PAs ourselves. Instead, we provide the tools that let providers automate their process in a self-service way.

We provide the APIs. That’s been the main driver of our growth for both the pharmacy management systems to do the integration and then also for the electronic health records. All of those systems can integrate using NCPDP standards or a REST API that can reduce the work effort needed to actually do that integration.

 

It will surprise people that there’s a company in a very specific, almost obscure niche that has grown so large and is still growing. Do you think you’re under the radar?

Yes. We absolutely are under the radar. But when you look at prior authorization, this is a problem that happens 200 million times a year. This is daily life in a pharmacy or a doctor’s office — 200 million patients that get their claim rejected and potentially will go untreated if this prior authorization process isn’t handled.

While it’s under the radar, it’s really contributing to that $350 billion or so problem of medication non-adherence. In a lot of ways, automating the PA process is the missing value proposition in e-prescribing. It doesn’t make a lot of sense to have an electronic prescribing process if the doctor is just going to then go deal with a fax or a phone call with the health plan. This has become something that’s much more top of mind as life goes on here.

 

A lot of software startups are trying to find a pain point they can resolve without competing with big companies like EHR vendors. What advice would you have for them?

Listen to customers and solve a big problem. Ideally, do that in a way that doesn’t involve taking a dollar from someone else.

What has really worked well for CoverMyMeds is that this is a way to remove administrative waste from a process without cutting reimbursement to a doctor, pharma company, or health plan. Because it’s truly a win-win for all participants in the market, we have alignment and the help of large companies to make this thing get big.

 

Your website says you have a chef that creates lunch for employees every day, which is a kind of a Silicon Valley move, but you’re in Ohio. What’s it like working there?

[laughs] We think we’re one of the best places for technology and business people to work in Ohio. We consistently are winning these best workplace awards.

As a software company, we’re nothing without the people. We look at both how do we give a lot more value than our customers expect, and then also how do we give our employees a lot more than they expect? That as a result of that has let us get some great people and then they stick around with us.

 

As companies grow, there’s always that decision about what comes next – do you acquire somebody, do you get acquired, do you roll out other offerings. Where do you see the company going from here?

Prior authorization seems like a very niche thing. It kind of is, but at the same time, it’s also right at the intersection where a doctor is making a decision about the tradeoffs between the cost of a treatment and its efficacy. We think that that’s a fundamental problem in healthcare.

We have built both the network and the connectivity and then also the relationships with pharma, payers, pharmacies, and providers. We think we can help doctors make more intelligent consumption decisions. We think is a very large opportunity, starting with drug, but helping to get to more personalized medicine in terms of prescribing, and then also other procedures as well.

Because of the growth of the size now, we have a lot of interest from the financial and strategic partners. We’re always willing to listen. We think this is a very big standalone company on its own.

 

What else could be done with the network you’ve created? You have an athenahealth-type model.

That’s right. We look at athena as a great big brother of the direction that we’re looking to go.

There are very obvious applications. First of all, we’re fundamentally solving the first step in patient adherence, which is get the patient on their drug. The next challenge then is keeping them on the drug. That’s an adherence angle that many of our customers are asking for help with. That’s something that that both pharma and health plans are interested in. We think there are interesting collaboration opportunities there.

The other thing that we’re very focused on right now is helping the electronic health records make this PA process something that happens at the point of prescribing. Right now, if you think about e-prescribing, what you basically have is a shopping cart. The doctor orders a drug and the patient may or may not end up being able to actually get that drug. We think that putting this PA process at the point of prescribing allows it to move from what’s an exception process to something that’s much more decision-supporting for the physician. We’re very focused on helping the doctors and the EHRs achieve that.

 

Do you have any final thoughts?

I’d really like to thank the HIStalk community and you guys. You’re a huge part of my daily reading list. I don’t think there’s a more credible and important intelligent source as HIStalk in the whole industry. I’d just like to hear from people about what they think.

We’ve been thrilled with how things have gone. In a lot of ways, this business looks a lot more like a consumer Internet company than a traditional enterprise software company because of that network effect. We’re solving something that for a frontline healthcare person is a huge struggle. That’s been one of the most fun things, really, something that truly can impact hundreds of thousands of providers that make their life better. We just celebrated that 10 million patients have now gotten the drugs they needed that they wouldn’t have otherwise. At the end of the day, that’s what keeps us coming in in the morning.

HIStalk Interviews Michael Oppenheim, MD, CMIO, North Shore-LIJ Health System

September 22, 2014 Interviews 3 Comments

Michael Oppenheim, MD is CMIO at North Shore-LIJ Health System of New York, NY.

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What is North Shore-LIJ doing with interoperability and HIE?

I’ll start at the end and then I’ll back up and explain the thinking that led us in this direction. 

We are making a huge investment — time, personnel, and focus — into developing an internal HIE, health information exchange. The reason we’ve done that — and I think a lot of other large integrated delivery networks have come around to this way of thinking — we were very eager participants when New York state initially put out the request for proposals to develop a number of RHIOs within the state. They’ve since consolidated — the HIEs, the RHIOs from across the state — into a single structure, SHINY, the State Health Information Network of New York. 

In the beginning, when you talked about doing internal HIE within an organization, everyone assumed that you were somehow trying to be exclusionist or not participate in the HIE. That’s far from the case. I think the state has come around on that, and many other IDNs have come to the realization that the kind of interoperability that we want to do goes much beyond what the mission and goals of the RHIOs are. 

The RHIOs are very, very much focused on getting as broad a look at patient information as they possibly can. That’s great because they help broker the politics and provide a common playing field for organizations that may be competitors in the marketplace, but are willing to jointly share data through the third party of the RHIO. You create a huge, consolidated record that people can go to and get a comprehensive look at the patient beyond just what they know from their four walls.

But there are a couple of things that HIE has come to mean to some of us that is beyond the scope of what the RHIOs or HIEs are focusing on today. One is around actionability of the data. The second is around not just aggregating and displaying data, but actually literally moving data from point to point without human intervention. 

The user experience with the standard type of HIE implementation is that the clinician first goes to the HIE or the RHIO to look up what history is there about this patient who I’ve never seen before. Then you go and you actually do your clinical documentation and order entry and everything else, in whatever transactional system, whatever EMR you happen to be using for your environment where you’re caring, whether it’s an office- or a hospital-based practice. 

There are two limitations to that in my mind. One is the intrinsic dissatisfaction with having to go to two places to look at data. The second being that the data out in the HIE is not necessarily actionable. I’m ordering a medication in my EMR and there’s a lab test that hasn’t been drawn in my office or hospital, but it’s known in the RHIO. Based on that lab test, I need a dosage adjustment or there’s a contraindication to the medication. My decision support engine doesn’t see that external data. 

Our focus has been on looking at how an HIE can bring data right to the clinician so that he or she can have one place where they do all their work, as well as have more of that data available for a decision support engine or for any rules or analytics or other things that you want to do on your data set, and have it all consolidated. 

We look at the HIE opportunity because internally, we can do a lot more. There’s a lot tighter integration and have a lot more actionability of the data by having an internal HIE that we control, that’s covered by our consents, and any number of other things that are facilitated by having an internal HIE.

We’re an Allscripts shop. We’re using Allscripts TouchWorks in the practice environment and  Sunrise in the hospital environment. We made this decision before the dbMotion acquisition and before some of the newer interoperability tools that they produced. Let’s put that off to the side for a moment.

The workflow that we wanted to enable was what we built so that when a patient comes to the emergency room, we pull a summary from the ambulatory environment. We place it into the Sunrise record, so it’s available and visible to the docs in the hospital. They don’t have to go out and look somewhere else. They don’t have to look at the HIE’s viewer, don’t have to look in the ambulatory record. It’s right there in the hospital environment.

At the same time, we use the data in some actionable ways. We’ve certainly done more sophisticated things than this, but even on the most basic level, we can fire off a notification. We can put a task notification in the task list of the primary care doc to say, do you know your patient is in the emergency room? If and when that patient gets admitted, we fire off a second notification saying, by the way, not only were they in the emergency room, they have been admitted to the hospital.

We begin to start to getting into what’s really business process management around the transition of care and moving the data for the user. Not requiring them to push it via Direct or something else — by sending off alerts and notifications to the primary doc so they can communicate with the hospitalist. That’s just one of the more basic examples.

To us, the HIE is much more of a process orchestration engine, not just simply a repository of data that someone can look at. It’s actionable. It’s delivered to the clinician when they need it, where they need it. That’s been the driving philosophy behind having an internal HIE rather than simply rely on RHIOs or outside entities.

The example I gave involves an ambulatory practice and a hospital. Certainly in some environments where you have a consolidated platform, maybe that’s not the most important use case. But even in hospitals that are using systems that share a record with their ambulatory facility, there’s always going to be other facilities in a large, integrated delivery network that’s not going to be on the common platform. We have nursing homes. We have a home care company. We have numerous other types of business entities that are relying on this flow of data so that their providers can work most efficiently in what we call the home system.

Whatever you’re used to work in, that’s where we want the payload delivered. That’s where we want alerts and notifications and things to arrive. That will be orchestrated through our HIE.

 

Will HIEs be challenged to provide business value to offset the cost?

If you look at where our future revenue opportunities are going to be, we’re moving away from our fee-for-service world and very much moving to the risk-based contract in a capitated world. We have numerous risk contracts with commercial partners. We’ve just launched our own insurance company, North Shore-LIJ CareConnect.

To us, orchestrating business process, eliminating redundancy by making sure that everybody’s got full access to the full corpus of clinical data, having a decision support engine that sits and looks at data and reacts to data across the entire health system … I couldn’t hand you a document today that says, “Here’s the amount of dollars I expect to improve my pay-for-performance and here’s how much I expect to cut my readmissions and here’s how much I expect to XYZ.”

But conceptually, we are all bought in that our entire financial success of the health system depends on the successful conversion to be able to do capitated and risk-based contracting. We don’t think we can do that without an HIE to coordinate the transition to healthcare managers and care navigators who identify patient activity, figure out who’s been where, get notifications when things happen that shouldn’t have happened, or get notifications when things that should have happened didn’t.

The HIE, for example, has in it the full ambulatory providers schedule. We can find if a patient has an appointment that’s been missed. We can fire off a notification out of the HIE. The HIE is so much more than information exchange.

The HIE platform also has registry function that allows us to load programs into it. If we have a heart failure program, we can either manually or automatically load in that these are all patients with heart failure that are part of this program. Or patients coming in with a certain payer. We can go into that payer registry and then we can make sure we do the right notifications to the right coordinators of those programs as either activity that should happens but doesn’t happen, or activity that shouldn’t happen but does happen, like unexpected specialist visits or ED visits or things like that. 

As an article of faith, we fully believe that in order to truly be able to coordinate care as an integrated delivery network and provide population health and be able to be financially and clinically successful in capitated arrangements or among our own insured population, the HIE has to be a critical enabler of that. I don’t have a specific financial ROI sheet that I can wave and say, “This dollar is going to be offset by that dollar,” but absolutely the direction of how the health system expects to care for patients in a longitudinal way and a holistic way requires this kind of technology.

 

Do you think the demands of population health management have turned the expectations for HIEs upside down? I’m referring to the RHIO-type organizations.

I’ll answer that in two ways. We’ve always had this intrinsic discomfort, as I started off by saying, that I’m going to look in point A and then point B and then point C, which is why we use the HIE as central consolidation point  to create a single, consolidated, comprehensive record which we can then push forward to the provider just in time as an encounter is about to happen. We anticipated that that kind of clinician reaction had to be overcome. That’s exactly why we did the things we did — get it in their face and not make them go hunt for it.

But how and when will the RHIOs retool? I think they have to. It’s really not as much their onus as it is the onus of the providers who are going to be held to different types of accountability standards to take on the responsibility to go search and find all of that data. That really is putting a tremendous burden on your providers. The value proposition goes up, but it’s on the back of the provider more than it’s on the back of the RHIO to do anything different.

The one thing, though, that I will say … I’ll editorialize a little bit … is that the RHIOs are being fundamentally pulled in the wrong direction on a lot of this stuff. Because at least in New York state, the privacy concerns around the RHIOs are, if anything, driving more and more and more restrictive rules around access to the data, sharing of the data, then sending us data. Within the context of a single organization that we control, we manage the consenting process end to end. There’s a lot more we can do.

When you get out into the state level or eventually the national level, a lot of the good intentions and the good clinical opportunities are potentially going to be stymied by the restrictive practices and policies that are being built around the RHIOs because of the patient privacy concerns. I don’t mean to minimize the privacy concerns. They’re certainly real and legitimate. But what they ultimately translate into from a regulatory statutory perspective, at least in New York state, runs a little bit counter to what we’re trying to accomplish by saying, hey, wherever this patient goes, we’ve got to be able to assure that everyone’s on the same plan of care. Everyone knows what’s already been done. It’s going to be very tough in the governmental RHIOs because of the privacy concerns and what they’re driving from a policy and practice perspective at the RHIO level.

 

You mentioned your Allscripts implementation earlier. I’m curious about how that’s going, especially now that they’re retooling into a population health management company.

It’s going well. We made this decision before they came forward with their dbMotion acquisition and some of the new tools that they’re bringing forth, which we’re very excited about. We just met with a number of them a few weeks ago. We have a whole bunch of folks coming on site.

We’ve been talking about population health management, trying to understand the respective roles for our internal HIE for what they’re trying to do to bring their products together. The newer front end that they have been talking about which fuses dbMotion with their front end products to make the community data and the local data appear seamlessly to a clinician look like a very, very attractive set of work flows. We are in detailed discussions with them about how we merge some of the things that we’ve done or are doing internally with some of the things that they’re doing, because we did set off on this track a little bit ahead of them.

 

What are your biggest challenges and opportunities as a CMIO over the next several years?

The HIE is probably one of the biggest. People think of it as a technology — and there is a lot of very, very valuable technology – but the HIE alone, just simply “data comes in, data goes out,” doesn’t accomplish the mission unless you build lots of clinical workflows over it and around it. You’re supporting any number of clinical programs or any number of potential patient flows or workflows. I have a big team focused just on that, which is working on how we take the power of the HIE and apply it to all the various different programs that are growing up around the system. That’s probably one of the biggest.

The other major area for us as a health system is the development of a data warehouse, which we don’t have today. We have a lot of individual analytic tools and products attached to our various EMRs, plus other types of warehousing — cost accounting, things like that.

We still have work to do with our EMR rollout. We still haven’t put physician documentation out beyond the inpatient space, beyond the admission and discharge documents. We still have to build out progress notes, consult notes, and a couple of other things. We still have about 30 percent of our medical group to whom we still have to roll out our ambulatory EMR. Those are all still in progress.

But my overall goal is to look at, as we make this transition to a different model of care, how do we orient everything we’re doing in the EMRs, align it with everything we need to do in the data warehousing space to provide the analytics that are needed to support these programs, and align all that with all of the clinical workflows that we’re building in the HIE to support the population health types of initiatives that we’re doing with the HIE? Making sure that all these three things work together properly, that they don’t overlap each other in what they’re doing, that we don’t leave gaps where I thought the HIE would do that or the other warehouse would do that. To make sure that all of these things align together to support all of the population health programs that we’re engaged in.

HIStalk Interviews Marc Grossman, Principal, WeiserMazars

September 15, 2014 Interviews 1 Comment

Marc Grossman is principal with WeiserMazars of New York, NY.

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Tell me about yourself and the company.

I’ve been in the healthcare IT industry for 30 years. I’ve worked on the provider side as a hospital administrator and have been doing healthcare IT consulting for about 25 years.

I work for WeiserMazars. It’s an international consulting and accounting firm. I head up the healthcare national practice within the United States. Our clients are all provider-side clients in healthcare IT.

 

How are hospitals selecting and implementing systems differently now than they were five or 10 years ago?

There’s really not been that much change in how they’re selecting core systems. Hospitals typically keep systems for 10 to 20 years, which is a lot longer than most people would expect. I think it’s due to financial reasons.

We’ve gone through a lot of clinical selections recently. Our emphasis was on clinical systems due to Meaningful Use. There’s a cycle that I see the industry going through in the type of system, whether it’s financial, patient accounting, clinical lab, radiology, and so forth. But the process is basically still the same. That hasn’t changed.

 

The pendulum always swings back. People are paying more attention to revenue cycle and even talking about customer relationship management systems. What systems do you think are poised to make a comeback?

Patient accounting is going to see a big shift. That also has a lot to do with the fact that Siemens is being purchased by Cerner. Lab systems are starting to go through a cycle again.

People have in the past three or four years started looking at systems that haven’t taken off significantly yet. Systems related to population health management, data analytics, data warehousing, business intelligence. Those types of systems will cause a shift in purchases.

 

What are you seeing with lab systems? 

We’re seeing a push for an integrated approach, getting away from best of breed. You see it with Epic. You see it with Cerner. Those are probably the two biggest right now that I see people moving to. If they already have Epic, they’re moving to Epic’s lab. If they have Cerner, they’re moving to Cerner’s lab. 

We have seen that in lab systems, there seems to be a cycle about every seven years. I’d say about half of organizations are replacing. They keep it for about 14 years, typically, and about every seven years, we seem to be doing a lot more lab system selections than we have in the past. I’m talking about replacement of whatever they have — best of breed or some kind of niche vendor system.

 

How do you see Cerner’s acquisition of Siemens unfolding?

A lot of it’s going to depend on where the Siemens client is. Are they live on Soarian or in the process of implementing Soarian? Cerner has been much more successful with their patient accounting system recently. They’ve changed the name because it had such a bad reputation – they no longer call it ProFit. 

I believe Cerner is buying Siemens for intellectual property. On the patient accounting side, I think they’re also looking at the RCO base that Siemens has, which is a great revenue stream for them. 

Given Cerner’s history and the industry’s history over the last 20-30 years, Siemens Soarian and Invision product support is going to go downhill. I think they probably won’t sunset it officially for at least 10 years, just because I know Siemens does have numerous contracts which are going out 10 years. I also hear Siemens’ sales guys are really pushing to provide great deals right now, to get people to sign up or extend their contracts for 10 years. 

Like we’ve seen with many other vendors that purchased other systems, Cerner is clearly not going to put R&D money into two patient accounting systems and two clinical systems if they have an integrated system now. I just don’t see any indication that Cerner is going to continue the development of any of the Soarian or Invision products.

 

What are you seeing with population health management and analytics?

We’re seeing a lot of disappointment because the systems are so early in their life cycles. People are hearing a lot of promises from various vendors, both the major players like Cerner, Epic, and Allscripts and down the line. They have products in their infancy.

Then you have the niche players, which definitely have more mature systems, but there’s still a lot of disappointment even with those. Difficulty with interfacing issues and difficulty with the depth and breadth part of the applications.

 

Is there a mature enough process in place in hospitals that even if the systems could give them what they want, that they could follow through on the promise of either population health management or analytics?

I’ll say eventually we’ll get there. I don’t think we’re there yet.

Some of the larger academic medical centers that have large IT shops, are more sophisticated, and have a lot more money to spend have gotten their feet wet, some of them 10 years ago. But a lesson we have to learn is that vendors and consultants set false expectations. It’s a multifaceted challenge that we’re dealing with in our industry.

The biggest problem we have is that our industry is the only industry that I know of where the revenue side of the financial equation is heavily regulated, but the cost side is totally unregulated. We have a ton of regulations, a ton of incentive programs, but the money isn’t there to pay for all the wants and the needs.

We also as an industry need to accept responsibility for the fact in that we don’t have real standards when it comes to interoperability. Each hospital thinks that it’s unique. I’m not suggesting that they’re not different in some ways and some have certain specialties that others don’t. But the reality is that they’re in competition with each other, so they’re not willing to share things where they should be sharing.

The other issue is that each individual hospital’s incentives are not in sync with the government’s incentives and drive. The government can save money by having hospitals operate in a certain way. Each hospital doesn’t necessarily benefit from it. The desire of where we’re going to put our money at each hospital is not consistent.

 

Is the era of hospitals running applications from their own data centers fading as they move to the cloud?

We’re at least five to 10 years away from that. I’m hearing from a lot of our clients – they want to get out of the data center business. I don’t know if it’s going to necessarily be the cloud. There’s definitely a push to move more to RCO-RHO kind of approach like Siemens and Cerner have been doing for many years.

 

When hospitals negotiate agreements with companies to host their applications in whatever form, what’s important for them to look at contractually to protect their interest?

Service levels, to make sure that response time and downtime is going to be sufficient. Address areas related to growth and the impact on fees. Also, the whole issue of who really owns the data and how do you access that data if and when the arrangement ends. It sounds like a simple thing, but the reality is that it’s often very difficult for hospitals when they’re trying to pull out of an RCO arrangement to easily get their data.

Those are probably the biggest issues in my mind — cost, access, and availability.

 

What are the top issues that are challenging health system IT departments?

What I’m hearing from most of our clients are four or five big issues. CIOs expressing concern that they have too much on their plates, not just individually, but as an organization. They have too many high priorities and don’t have the necessary resources in most instances. ICD-10, Meaningful Use, the related offshoots from all of that, population health, changes in reimbursement, growth in terms of hospitals buying up physician practices or buying other hospitals or merging.

A second category is lack of strong IT governance. A lot of what relates to that unfortunately at many hospitals, especially at smaller hospitals, CIOs still do not have a full seat at the table. They’re often viewed as not being strategic. A lot of the hospital executives still view IT as a necessary evil rather than a strategic enabler. It becomes an uphill battle for CIOs.

There’s a lot of frustration and lack of trust among a lot of the executive leadership at many healthcare providers due to the history of false promises and expectations that were not met in the industry over the many years. Look at how many failures we’ve had with just EMRs alone and how organizations have had to replace systems.

Even in this day and age, I find a lot of executives don’t understand what systems are going to really give them and that systems are not going to solve all their problems. It’s just an enabler as opposed to the solution itself.

 

Do you have any concluding thoughts?

We’ve actually grown a lot as an industry. I think we still have a lot of growing to do.

An HIT Moment with … Travis Bond

September 10, 2014 Interviews 1 Comment

An HIT Moment with ... is a quick interview with someone we find interesting. Travis Bond is founder and CEO of CareSync of Wesley Chapel, FL.

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Consumers have voted with their feet in failing to adopt personal health records platforms that require them to maintain their information manually. How is CareSync different?

Traditional PHRs have failed for a lot of reasons, but it ultimately boils down to the fact that gathering and organizing health information is a lot of work. A complete hassle, actually. Let’s face it, unless it’s out of necessity, it never becomes a priority for most people.

We recently did some interviews with a handful of our users and almost everybody said the same thing: “I knew that I needed to get my hands on this information, but just the thought of getting it overwhelmed me.”

We obviously love technology and I believe that the ball is moving in the right direction in HIT, but we’ve got a long way to go before technology solves the data, communication, and care coordination problems that plague healthcare. Collecting medical records from various providers is a hassle, the data is fragmented across various health systems and providers, and even if you manage to get them all together, the information isn’t particularly meaningful.

We often have internal debates whether or not we are a PHR. We are in many ways, but our approach is completely different. It’s not just the high tech, but rather the combination of great technology and high-touch concierge services to connect people and data and truly redefine the role of the patient in healthcare.

We have a team of people who gather all of a user’s available medical records from all of their providers. They enter data such as health conditions, medications, and allergies into structured, codified fields. They build a digital record of each past medical visit, including the provider’s assessment and plan. This comprehensive Health Timeline is easily filtered and electronically transmitted to providers directly from the app.

Users add family, friends, and other members to their care team. We believe in the “it takes a village” concept when it comes to managing healthcare, so family and other caregivers can help with tasks, appointment prep, and medication compliance. They receive notifications and alerts to help their loved one stay on track.

Our latest release includes tracking and measurements. We’re layering clinical data with patient and family-generated data in the form of journals and pain scales, vitals, and behavioral data with integrations with tracking and wearable devices.

We make the data accessible, useful, easy-to-understand, and even easier to share with the people who need access to it.

 

How do you sell subscriptions to consumers without spending a fortune on marketing?

We focus our marketing energy and dollars on targeting the population where our solution meets a true need today. That’s primarily people who have a chronic illness and the people who help take care of them. We’ve been successful with social media engagement, speaking at events, and doing some targeted advertising. We have partnered with some chronic and rare disease organizations as well.

We also sell CareSync to businesses, including hospitals, payers, employers, pharma, and even universities. Each use it a little differently, but everybody benefits when people are healthier and engaged in their care. Employers are offering it as an employee perk and to reduce their healthcare costs. A specialty hospital is relying on our newly released Pro version that functions as a communication layer between their organization and the patient and caregivers.

Very satisfied customers, word-of-mouth, and people adding family members and other caregivers who quickly become paying customers helps, too.

 

What’s different about creating technology for patients and families instead of for doctors?

This is somewhat hard to say without sounding harsh, but we believe the biggest difference has been how appreciative patients and caregivers are. We get calls and letters every day from our users who are thankful for how we helped them better understand their condition, prepared them for an important visit with a super specialist, and helped carry the burdens that come with being a patient or caregiver. It’s very satisfying knowing that what you’re offering really does make life better for the people who use it.

All that said, doctors are really benefitting from CareSync, too. One doctor I recently talked to told me that it was a breath of fresh air to, for the first time in his career, have access to information from his patients’ other doctors. Like patients, doctors are also really frustrated by the system and truly do want to help their patients.

We have seen CareSync reignite the fire for a lot of doctors by giving them data and engaged patients. One user shared that her doctor hopped up to sit next to her on the exam table to go through her CareSync data. She left the visit with a long-awaited diagnosis and a high five from the doctor.

It’s a refreshing reminder that healthcare can be better.

 

Healthcare is the only industry in which its ultimate customer has had little voice and is almost lost in the business model. Can that be changed and can technology help?

The only way that healthcare will really improve is to get patients and their families involved, equipped with information and tools to manage and share it, and enough convenience to make them want to participate in what has traditionally been a frustrating and often overwhelming experience.

We have to redefine the role of the patient and give them a voice and unprecedented confidence in choosing what’s right for them.

It’s not just about cost. It’s about decisions around quality of life and personal preferences. It’s about helping the healthy stay that way and not making people feel so vulnerable when they are sick.

 

You’ve been in healthcare IT for a long time. What are the most positive aspects of it that you are seeing compared to a few years ago?

In 2003, I actually said, “How hard can it be to build an EMR?” It didn’t take long to realize that doing anything in healthcare is more of a challenge than it should be. I believe we’ve made a ton of progress in creating standards. We are starting to move toward accessible, cloud-based solutions.

There are a lot of really intelligent innovators and entrepreneurs tackling the inefficiencies of healthcare, building really great solutions. Change is happening. Technology and the power of the Internet are finally starting to help healthcare like they have in just about every other industry.

Patients are starting to wake up and say, “Enough is enough.” They are equipped with always-on smartphones. People are starting to apply the age of consumerism mentality to their healthcare. Once we get there, that’s where we’ll see the tide shift.

HIStalk Interviews Jeff Surges, President, Healthgrades

September 8, 2014 Interviews No Comments

Jeff Surges is president of Healthgrades of Denver, CO.

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Tell me about yourself and Healthgrades.

I’ve been around the healthcare ecosystem for close to 25 years. I’ve spent a lot of my time on what you would traditionally call the vendor community in multiple settings — private companies, small and large companies, publicly held companies, and hybrid companies.

I’ve served in many different roles, mostly client- or customer relationship-facing roles as CEO and founder. Then in an operating role helping our customers — whether that’s hospitals, physicians, or extended care providers — efficiently maximize their resources to achieve the results set out by that particular project.

I’ve worked in all settings for multiple years. I think that’s code for, “I’m getting older.” It’s certainly an exciting time again in healthcare for all of us as we see more transformation happening.

Healthgrades is a multi-faceted company that I find amazing. It is a place where nearly one million people a day visit to find the right doctor, the right hospital, and the right care based on a number of ways to search our database of physicians and hospitals by diseases, conditions, or procedures. That starts the information gateway into Healthgrades.

Traditionally, Healthgrades was only in the quality business. It would use publicly available data to run a process of looking at quality metrics and quality data and help hospitals that achieved those results make their community aware of their prestigious status.

Eventually over time, Healthgrades — by partnering with a private equity firm out of New York, Vestar — added two additional components to the value proposition. One is a business that centers itself on CRM, or customer relationship management. The teams work with hospitals on patient engagement, patient access, and what would we now call today population health initiatives. But I think truly I’ve found a place where pop health is real.

Then also, because of the amount of information that the company has on doctors, hospitals, physicians, and care settings, we have a media portion of the business that works primarily with pharmaceutical companies bringing information real time to the point of search based on a consumer’s interest or activity from the site.

Quality, CRM solutions, and a consumer portal that’s leading the industry every day with nearly one million visitors per day.

 

A lot of sites offer doctor search. How is the demand for that changing and what are people doing with the information?

As we’ve seen over the last three or four years, transparency is becoming more and more important. As the healthcare landscape is changing, the informed consumer is finally awakening to the same destination we go to for other activities, whether we’re looking for a vacation, a home, a car, or a restaurant. If I’m new to a market, have a new health plan, or I am signing up for a personal plan, I want to search for my healthcare now and take more control of that.

The brand of Healthgrades is tried and true over a long period of time as being a trusted resource providing great transparency. The database we have on physicians, hospitals, procedures, and conditions and the ability to be flexible and to showcase those results at the point in time where those results are needed.

Of the visitors we get to the site every day, we know that within a week, an overwhelming majority of those – more than half of them — are going to schedule an appointment with a physician. You’re on the site to conduct some real-time, emotion-filled information search. Healthgrades has become a trusted resource over time as that destination on the consumer side.

 

Organizations pay to use their Healthgrades rating for marketing. How does the company make money otherwise, including from the search function?

The real misnomer traditionally on Healthgrades has been that there’s an award and then there’s a monetization of the award. What I’ve learned quickly from some of our top clients and customers is that the hospital achieves the awards. They’re achieving that through a methodology that the company has developed using publicly held data and information and then comparing that regionally and nationally. They achieve these awards based on their results and their performance.

The marketing department of a hospital — who is waking up every day more than ever trying to gain awareness and to inform their communities because competition is really high right now — has been engaging with our CRM platforms on a variety of communications. One might be that if you’ve achieved that award, to let your community know that you’re hospital excels in a particular category. Healthgrades has a platform in the marketing solutions area that helps hospitals inform their communities when making that tough decision on finding a doctor, hospital, or specialist.

 

Is there a solution to the problem that multiple services offer their own version of ratings or rankings and consumers can’t figure out which one to trust?

Unlike normal Internet search where you would go to a particular search engine, type in a key word, and then get multiple pages of information, those are more for convenience people that are looking to shop or looking to plan. What we know about healthcare is that when you need it, it needs to be there. It needs to be an actionable transaction. It’s got to be trusted.

With Healthgrades specifically focused on finding the right doctor and helping you search, finding the right hospital, and making you aware of the right care setting at that point in time, what I’ve come to appreciate quickly is how we’ve differentiated ourselves because of the longevity and the depth at which the company is using information to help you with that.

There is a lot of activity of people trying to be the next site and the next site. It reminds me years ago when the 1-800 services were around. Ultimately you had to get to a trusted resource. Healthgrades continues to lead in that. That’s one of the things that excited me about the company.

 

The company is using large data sets, some of which are publicly available. What are the possibilities with so-called big data?

I’m going to have a better answer in a year, but in my first 100 days with the company, what I have really respected about the interaction we have with the consumer, physicians, and hospital clients is the notion that there really is big data in IT.

What will continue to separate Healthgrades will be the ability to expose the data, expose the information, and present it in a way that gives you an informed look.

The term population health is trendy right now, but when you’re working with a hospital that’s trying to identify an aging population or segmenting them by a different category other than just gender, race, or payer type … you’re going to get into the disease, condition, or procedure because you want to let them know about screening and immunizations. You want to let them know that you’ve done some risk stratification and want to contact them because they haven’t had a scan or a screening done. Or you want to identify an opportunity because of the seasonality of allergy or flu.

There’s some real predictive models of data that Healthgrades has at its fingertips. It’s the first company I’ve worked at where the title “data scientist” is not just one or two people, but groups of people working side by side with the hospital’s team to identify those populations in the CRM platform and communicate with them across multiple channels. Not just print, social, digital, and electronic, but taking all those together to get the message out to the community.

It’s more than just, “come to our website.” It’s about keeping healthy in a time where people are looking to trust a resource to guide them on how to do that.

 

Healthgrades was acquired by a private equity firm a few years back. Having been through that in different places, how does that process work and what’s good and bad about it?

It comes in all shapes and sizes. There are varying degrees of the overall objective.

In the case of Healthgrades and their partnership with their investors, it’s about leveraging the Internet. It’s about leveraging the consumer’s activism. Being patient enough to understand that healthcare is an evolving industry that has survived the test of time.

In many ways, a large private equity organization thinks about a long-term strategy and wants to see that strategy initiate over time. I’ve been part of companies where you have a start-up, an early stage, a venture backed, or you have a smaller private equity that wants to go public. All of those can be good to support what the company’s trying to do at that point in time.

What I’ve come to appreciate and respect about the Healthgrades model is that, in many ways, we’re still at the beginning. Healthgrades is on the patient acquisition, patient engagement, and ROI side of the model at a time when healthcare is looking to see who the survivors are. There’s been so much consolidation through acquiring specialists, physicians, or other hospitals.

There’s a need at the board level of hospitals and at the CEO level of hospitals to start to think about delivering on the promise that a large, integrated network would mean more revenue, more growth, or more sustainable balance sheets.

Being on that side of the equation is new to me, but it’s also very exciting when you see the conversations that are going on around strategies on patient access, patient engagement, and population health initiatives.

 

What are the most important things that will tell us where healthcare IT will be in five years?

It’s a big question. Those of us who have been around for a few generations now have always thought that the next big thing was going to be the one that pushes healthcare over. Yet whether it was a supply chain era, the EMR era, and now as we move into the big data cloud computing analytics era, it’s just an evolution. It continues to evolve. Demand, the population, payer mix … there are too many forces to even predict it.

The biggest thing we need to do is help our customers who are in the center of it. They’re in the center of transformation, whether it’s governmental, planned change, accountable care, compliance, or quality. Helping them achieve those results in real time. Because to be here for the next wave means you have to survive and thrive in this wave.

Long term means one to two years in many ways. The results of our clients are the most important metrics we can be thinking about.

On the Healthgrades side, we help our clients gain better access to information, use that to target their audiences and their communities, and make sure that those who are approaching them are the most informed and can be the most efficient. Not only for that individual or family, but for the services that the customer wants to provide or the health system wants to provide.

 

Do you have any final thoughts?

It’s an exciting time. You’re going to see three things coming from Healthgrades.

One is a re-introduction of what I call the new Healthgrades. We’re going to be releasing a lot of data and analytics about our ratings in the fall and using very expressive ways to show how our methodologies can partner with quality and outcomes within a hospital.

If you lined up the T-bar and said on the right side is cost and then the left side is revenue, there is great hope and interesting opportunities helping our healthcare clients — physicians, hospitals, and post-acute settings –survive in this area. Using a CRM platform intelligently with data and analytics is very big.

But healthcare is very local and will always be, and so real-time information and access is going to continue to be of utmost importance. Mobility, social, and interacting with the various platforms is going to continue to challenge us.

That’s an exciting area to be in right now. It’s why I found Healthgrades and Healthgrades found me. It’s been a great fit right out of the gate.

HIStalk Interviews Charlie Enicks, VP/CIO, Georgia Regents University and Health System

September 1, 2014 Interviews 1 Comment

Charlie Enicks is VP/CIO of George Regents University and Health System of Augusta, GA.

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Can you describe the contract you just signed with Cerner?

Cerner has similar arrangements in a couple of places. At University of Missouri, they call it the Tiger Institute. They just recently did something at Children’s National in Washington called the Bear Institute.

They agreed to a long-term agreement that sets out a way of operating and allows us to, from a strategic standpoint, innovate with Cerner and with Cerner and Philips. We’ll have an innovation committee that has a membership from our research and clinical group, from Cerner, and from Philips to talk about what could be either three-way or two-way innovation. We’re very excited about that part. 

What it allows us to do from a strategy is accelerate the pace of implementations that we can get done here. With our current financial situation, we can’t really get capital at a fast enough pace to get done what we want to get done. This contract smooths the cost out over 14 years. The Year 1 rate is lower and in the out years, the operating side is about equal to what we’d expect and the capital side is lower because of the investment Cerner is willing to make.

That includes moving the Cerner software and data to Kansas City to their data center. It includes moving the service desk to Kansas City, where it will be open 24 hours day, seven days a week, whereas we’re operating 14 hours, five days a week, which is problematic in a clinical environment. Ten senior associates will relocate to Augusta and work here. Five of those employees will be focused on innovation and process improvement projects that we plan to undertake.

It improves our disaster recovery and security profile. We have started putting together plans to operate a warm site. We’re looking at an investment of five to 10 million dollars to do that, so we avoid that step.

 

Which employees will not move to Cerner?

I’m responsible for the university as well. The university applications, our audio-visual effects, our client services on the university side will stay with the university. I’ll have CMIO, a chief information security officer, my university operation, and the administrative. We’ll still be doing all the contracting for non-Cerner applications and hardware.

 

Are they taking over the entire operation?

They’re taking over the operation of it and they’ll make recommendations about different things, but we do the procurement. It could possibly pass through Cerner if Cerner can get a better deal for us, but it’s not a requirement.

 

Fourteen years is a pretty long contract to lock in. What led you to have the confidence in Cerner to be willing to do that?

We’ve worked with them for 12 years. The 14 years was picked because of our Philips arrangement — it started last year and was a 15-year deal. We wanted those to be concurrent. There are typical ways to get out of the contract should either party decide at earlier than 14 years that it really doesn’t make sense.

My personal experience with Cerner went back to Emory back in the early 1990s during the genesis of the Millennium software. But I had not worked with them for almost 20 years. In the last two and a half years, I’ve been very impressed with where they’re going with their company, the services that they’re offering, and the direction of software.

Our access to capital is limited. Our growth strategy as an academic medical institution is creating enough clinical work for our students and residents. We’ve got relationships all over the state.

For us, this represents a way to get done what we need to do. We don’t have the capital to switch to some other vendor. We’ve decided to become a strong partner with Cerner. We think that will get us where we need to go.

 

Do you think it will become common that hospitals will be looking for someone to do their hosting or move to a cloud-type environment?

I would absolutely agree this is a trend. You’ve got companies like Novant in North Carolina — they’re starting to do this in the Epic space — and other companies. You’re going to see more and more of it.

Cerner recognized that. I guess they started the remote hosting a little over 10 years ago. But their ITWorks component of this, and their new software like the population health management, which is a cloud-based solution — that’s really where they’re moving as well.

I agree, I think this is going to be more and more the case as this stuff gets very complex and expensive to manage. Even though Augusta is an attractive place to some people. It’s very hard to recruit senior-level Cerner folks to Augusta.

 

What other things are you struggling with?

Like everybody else, we’re struggling with getting Stage 2 Meaningful Use tested. We’re very close — we still have some transition of care. We need to get those numbers up a little bit. But we’ll get that done.

Our issue predominantly in the clinical space is that we’ve had the product for a long time. We need to optimize what we’ve got, but we also need to get in the oncology module, the anesthesia module, and the maternity module. That’s really what’s keeping me up. Before this opportunity, I really didn’t see a way out of being able to get all that done in a timeline that the clinicians needed to do their work.

For the other projects that I’m worried about it in the health system, Cerner will be responsible for managing those. We’re doing a total voice over IP replacement for the university and the health system. Cerner will be managing it. We’re doing a consolidation of our Active Directory. We will still be buying the software, hardware, or services. Cerner will be responsible for executing.

 

Do they have those resources or will they staff up to meet your needs?

They do have a fairly extensive number of resources. They’re not sitting on the bench somewhere not doing anything, but we would be the 17th or 18th client that utilizes their ITWorks service. They’ve got a pretty extensive group out of Kansas City doing this now.

HIStalk Interviews Chris Longhurst, MD, MS, CMIO, Stanford Children’s Health

August 20, 2014 Interviews 9 Comments

Christopher Longhurst, MD is CMIO of Stanford Children’s Health, founding program director of the clinical informatics fellowship of Stanford University School of Medicine, and clinical associate professor of pediatrics and biomedical informatics at Stanford University School of Medicine of Palo Alto, CA.

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Tell me about yourself and your job.

I’m the chief medical information officer at Stanford Children’s Health. I have a faculty appointment in pediatrics and a courtesy appointment in biomedical informatics at the Stanford School of Medicine. I help to lead our clinical information technology and strategy for the health system as well as the academic fellows training program.

 

The new clinical informatics board certification allows physicians working in an informatics role to be grandfathered in for the first few years. Can you describe how you see that morphing into the requirement that applicants complete a clinical informatics fellowship and explain how your program is structured?

This started in 2011 when the American Board of Medical Specialties approved informatics as a board-eligible subspecialty. It’s a particularly unusual subspecialty because you can board in a subspecialty after training in any of the 24 primary specialties. Until 2017, people can grandfather in through extensive work experience and education, after which time the only way to be board eligible will be to have completed an accredited fellowship training program.

 

What is the audience that you anticipate will sign up for the fellowship?

When we opened the Stanford clinical informatics fellowship last year, we got dozens of applications. Some of those were from physicians with strong computer science backgrounds who wanted to write code and develop apps. While they have an important place in the ecosystem, that’s not what the fellowship program is looking for.

We’re recruiting physicians who are interested in driving improved healthcare delivery outcomes. We’re looking for people who are going to keep their eye on the ball in terms of where we’re headed and using informatics and IT as a tool to improve the delivery of the care that we provide. 

We’re really excited about our first two fellows, Lance Downing and Veena Goel, who are doing some amazing work and will be future healthcare leaders. In fact, the mission of the program, we decided, was not to train physicians to become informaticists, but to train the next generation of healthcare leaders in the skill of informatics.

 

Once the grandfather period is over, who will offer fellowships for those people working in an applied informatics CMIO role that isn’t research based but rather feet on the ground technology adoption?

There are 140 or so medical schools in the United States and 6,000 hospitals. If the fellowship programs are only at those academic medical centers with medical schools, we’re not going to train enough people for the next generation of healthcare leaders. I anticipate, though, that we will see training programs coming up at non-academic medical centers.

In fact, I think it’s important that that happens just as with other specialties. We have internal medicine programs at over 800 hospitals. I think we’ll see opportunities for training informaticists at many, many other healthcare settings.

What’s different between this and the master’s degree programs of the past is that these fellowship programs offer experiential training. It’s the opportunity to come in, be part of the office of the CMIO or other applied clinical informatics environments, and contribute in a meaningful way to real projects. I think that this type of experiential training complements the didactics, but is a critical piece for training our next generation.

 

The Institute of Medicine’s recent review of medical education questioned why it’s only offered in hospital settings. Why wouldn’t a public health setting for informatics training be equally desirable given the need for population health management?

As part of our fellowship program, we offer rotations not just at the two hospitals at Stanford, but also in the clinical research informatics group at Stanford medical school. We also offer elective rotations in the industry. Our fellows have the opportunity to spend a month at a large company like HP Labs, where they do healthcare analytics research, as well as at a small startup company, Doximity. We think that there are physicians who are going to be working in all sorts of settings and having those experiences is important.

We also have our fellows rotating through the Kaiser and Sutter healthcare systems, where they have an opportunity to see a large, integrated delivery network that’s not an academic medical center.

 

What subjects will be covered in the two-year fellowship?

We break it down as follows. We think that it’s important that our clinical informatics fellows maintain clinical activity. They’re expected to spend 20 percent of their time seeing patients. We’ve partnered with Bill Hersh and the Oregon Health & Science University distance learning program to provide didactic support, so we anticipate they spend another 20 percent of their time with the classwork. That leaves 60 percent of their time, which is a combination of these experiential rotations and unstructured time for scholarship and longitudinal projects.

 

The OHSU program is rigorous and you are adding additional elements to it. It will take some work to complete the fellowship.

[Laughs] Well, we expect that the fellows will be working hard, but we also think it’s going to be a really gratifying program to complete training.

 

What training are medical students receiving in practicing with an EHR and then performing data analysis for research or for population health management?

At most health systems, the training for medical students is pretty limited. They may get a little introduction to the electronic health record systems, but it’s generally focused on the front-end data input and review on single patients, not on population health. Dr. Bill Hersh just co-authored a publication suggesting new competencies for undergraduate medical student training in informatics. I think that we’ll see adoption of those concepts widely moving forward.

 

Everybody wants to get their specific area covered in medical school education, but it’s already a busy program even though informatics is in some ways as important a stethoscope or a scalpel. Do you think the 10×10 program is meeting that need now and will that change over time?

I think the AMIA 10×10 program has played a really important role in raising the bar on informaticists. Ten years ago, any consultant with experience in clinical information systems could declare themselves an expert. But having some formal classroom understanding of what’s happened in the last 50 years in this field and where the grand challenges lie is important for coming together as a field to attack those big problems.

 

You’ve done work with a “patients like mine” button idea where a doctor can quickly find similar patients to the one they’re seeing. Are you doing that or is it still a concept?

We have an exciting story that was published in the New England Journal of Medicine in 2011. The story was about a 13-year-old girl with a known diagnosis of lupus who was admitted to our hospital with a flair in her lupus. One of my colleagues, Dr. Jenny Frankovich, asked a really important question, which was whether her lab findings made her at higher risk for clotting and whether we should consider prescribing anticoagulants for her.

Of course, we did what any good evidence-based clinicians would do and looked in the literature, but as in many special areas of pediatrics, there was no literature on teenagers with lupus and risk of clotting. We then asked our colleagues, and the first colleague we asked said absolutely you should anticoagulate. The next colleague we asked said absolutely not. We were left holding the bag with one of these clinical decisions that occurs every day across this nation, but has to be made in the absence of data.

My colleague Dr. Frankovich did something at this point which had not been done before. She used her IRB-approved access to a data warehouse to look at a holistic experience with teenagers with lupus at Stanford over the last five years. She found 100 similar patients, and on the day that we admitted this teenager, was able to determine that her lab findings put her at six- to seven-fold increased risk of clotting. Based on that, we made the decision to anticoagulate her. That was the experience that launched my interest in using aggregate electronic health record data for point-of-care decision making.

We just published in Health Affairs last month in the big data issue the concept of a green button. Just as a blue button is both a metaphorical and visual indication of patient’s abilities to download their own data, the idea behind the green button is that in the absence of good peer-reviewed evidence on a clinical decision, that you would be able to use the aggregate data in your electronic health record — or perhaps federated across multiple databases — to generate real-time, personalized comparative effectiveness cohorts, or “patients like mine.”

Imagine if you saw a 55-year-old woman with hypertension, asthma, and of Vietnamese heritage. Recognizing that this lady would not fit well into the American Heart Association guidelines, you could look at the experience of all 50- to 60-year-old Vietnamese women with hypertension and which medications have the most efficacious impact.

This could really change our clinical decision-making and our cost effectiveness and value of care across the United States. But there will have to be some important policy changes as well as technology developments to ensure this happens in a systematic and formalized way.

 

Kaiser has done interesting things given their huge database and control over all care settings for their patients. The PCORI project generates cohorts across participating health systems. Do you see the use of data going beyond the four walls to make clinical decisions as a trend?

Absolutely. I think a lot of good work on interoperability of databases is occurring. I2B2 is one example. PCORI is another and the PCORnet. Kaiser and Geisinger have been leaders in using their own data sets to make more data-driven decision about what medications they offer on formulary, for example.

But I think ultimately we need to get to a point where rather than go into a group of analysts and researchers to mine data for six to 12 months, we need to enable the clinicians with the right tools to do these queries at the front line of care. That’s really what the green button concept is about.

 

Do you think that’s a significant argument for virtual affiliations? The six Wisconsin hospitals jut announced plans to work together to share patient information from their Epic systems.

Unquestionably. In fact, we use the Epic electronic health record system at Stanford. One of the things that’s really exciting to us is the amount of data exchange that’s occurring in Northern California. We have such a high rate of data exchange that in the first 10 weeks on the Epic system at the children’s hospital, we connected with over 35 outside institutions for over 30,000 patients.

We know that enables continuum of care for our patients who are receiving primary care elsewhere as well as for the subspecialty care that we offer at Stanford Children’s. But the next step is using that data to provide better analytics for population health. The Wisconsin example that you describe is a great pilot and prototype for what I believe will occur increasingly as we move forward.

I should also mention that one of our clinical informatics fellows, Dr. Downing, is actively working on a project now to look at data exchange in Northern California in a 360-degree view. Most studies to date of healthcare information exchange are focused on what it means to the emergency department that they can get outside data, but in fact, the major use case that we’re seeing is that we offer tertiary care services and a lot of our patients get primary care elsewhere. 

We’re really supporting the continuum of care. Being able to look at data that’s sent and received from the perspective of multiple different health systems in Northern California is one of the benefits that this fellowship offers.

 

Putting on your CMIO hat, what are some other interesting projects that you’re working on?

I also have the opportunity and privilege to lead our analytics and data warehouse team. I believe, as in the green button concept, that the future of leveraging these electronic health records is going to be how we use it not just for the care of an individual patient, but for the care of populations of patients. 

We’ve got a number of innovation pilots in our analytics team. My colleague Dr. Jon Palma, who’s also the associate program director for the fellowship, is leading some exciting work in text analytics that’s already benefited our hospital in an operational way. We’re also looking at predictive analytics and forecasting. For example, our census report right now looks at historical trends. Shortly we will be adding the ability to forecast census trends for the next week.

 

Any final thoughts?

Stanford is accepting applications now for 2015-2017 fellows in clinical informatics. We welcome applications from candidates of any any clinical background.

I would close by saying that we’re at an exciting junction of the field. I believe in the future, as we see more and more physicians involved with health information technology, that this board certification will become a mark of somebody who’s achieved a certain set of core competencies and will be increasingly important across the spectrum of physicians working in these settings.

HIStalk Interviews Jan De Witte, CEO, GE Healthcare IT

August 4, 2014 Interviews 7 Comments

Jan De Witte is president and CEO of GE Healthcare IT.

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Describe your job.

I run our healthcare IT business globally. I would summarize it as four big categories. Enterprise imaging. Care delivery management — care pathways inside the hospital in the departmental areas and ambulatory care. Population health management, our joint venture with Microsoft in the Caradigm company. Then financial management, revenue cycle management, and cost analytics or margin management. 

We have different global product managers that run these categories. We commercialize and implement our systems pretty much across the world, with the US as the main market. The US makes up more than 60 percent of our business activity.

 

What is the status is of the Healthymagination project?

Healthymagination started several years ago. It is a focus of GE and GE Healthcare to drive outcomes in healthcare, specifically cost, productivity, and clinical quality outcomes.

As of two or three years ago, that program has matured in the sense that it has changed, shifted how we do product management on our equipment and our software. Our product managers start with outcomes in mind and then develop technologies that drive those outcomes. Before, we often — like many other companies — developed great technology without necessarily touching the outcomes that our customers needed. 

That’s how I would say Healthymagination has morphed from initiative several years back to today — a different culture and capability within our project management.

 

Siemens is another multi-national conglomerate and they apparently want out of the healthcare IT business. How do you see GE Healthcare IT positioning itself going forward against competitors that focus exclusively on healthcare IT?

On the Siemens-specific question, I’ve gotten questions from both customers and our employees.

There’s two elements to be asked. First, GE Healthcare, my mother company, is fully committed to driving outcomes in healthcare. If you look at the challenge for healthcare, it’s information technology that is going to be the big enabler to drive both productivity and quality. Going back to what we said on Healthymagination, we’re more than ever committed to building out our healthcare IT capabilities to fulfill that mission to make a difference in healthcare.

For the second dimension, I’m sure you’ve heard about the industrial Internet and Jeff Immelt’s commitment to building out GE’s software capabilities. What’s true in healthcare is true in many other industries. The next generation of driving improvement is going to be linked to data, analytics, and using those insights to drive better processes. From Jeff Immelt down, there’s more commitment than ever to be a significant player in software.

Those two together — my direct manager and Jeff Immelt — are fully committed to building out our healthcare IT capability. Close to half of GE’s software activity. Getting a lot of help and support from our San Ramon center of excellence to build out capabilities.

 

Describe how the industrial Internet fits into what you’ll be doing differently within your software areas.

Let me start with the vision of the industrial Internet. The way we put it is minds to machines can bring intelligence to machines or through machines that generate data, no matter which industry you look at. Process improvements, if you only take one percent, it’s tremendous value you can generate.

The vision of GE is, let’s complement our deep capabilities in developing excellent machines with deep software capabilities to complement those machines, take the data that comes off these machines, and make either the machines or the process around the machines more efficient. This can go from reading data from jet engines and understanding how to make them operate at higher fuel efficiencies to taking planning information from train scheduling and optimizing, planning, and routing and asset utilization in railway operations.

I’ll come to healthcare in a minute, but the commitment of GE is translated into our center of excellence in San Ramon on the West Coast, where we have about a thousand engineers today building out a cloud-based platform which we call Predix. Essentially it is all the next-generation cloud-based platform capabilities that either myself or colleagues of mine in other GE businesses will leverage to build analytics and workflow solutions on.

Very concretely, the industrial Internet initiative of GE is providing me, as a healthcare IT leader, with next-generation platform capabilities that over time will be reflected in the re-platforming of some of my current legacy applications, or brand new analytics applications that we’re building on the Predix platform right away.

 

How do you see the role of Centricity and how will that change with the industrial Internet?

Centricity is essentially the umbrella brand across the breadth of our portfolio. A couple of years back, we made a decision to focus the Centricity portfolio on what internally we called the next innings in healthcare. It’s clear over the past five-plus years that the whole healthcare industry has been focused on digitization — turning film into digitized information, turning paper into digitization with fax systems and with EMR systems. That’s only the first stage in any industry that goes through an industrialization phase.

We decided, from an R&D perspective, to start focusing on the next innings, which is going to be about analytics and workflows. We start to see today the next inning taking shape. 

Within the Centricity portfolio, if I  look at our Centricity enterprise imaging solutions, today those solutions are focused on enhancing diagnostic speeds and diagnostic confidence. Not just within one department, but across the enterprise, even across regions or countries. The same for our care delivery management, whether that’s Centricity anesthesia or peri-op solutions or ambulatory EMR. They are increasingly becoming systems to enable predictive care pathways. Our revenue cycle management solutions are increasingly becoming risk and profitability management tools.

With our products, all of them, our R&D is focused on providing analytics capabilities and workflow capabilities in these tools rather than digitizing. The Predix platform is a service-oriented cloud-based platform that is enabling us to build out the analytics capabilities, to build out the right user interface and user experience, and to build out the security capabilities that we are needing in that next generation of IT solutions for healthcare.

 

Are we in a post-EMR era and moving to analytics, connectivity, and the power of the network?

The short answer is yes. We are, definitely. I hear that from many of our customers. It started one or two years back when they said, we’ve invested a lot of money in bringing in a great EMR. We have realized today that we are not really changing our operation yet. In fact, in some cases, our physicians are less productive than we thought because they spend more time inputting data into systems.

There’s a little bit of a disappointment of the realization that the EMR is, I would call it, the necessary evil to enable the real phase of information technology, which is turning all of that data into actionable insights, and then using those insights into different workflow applications that enable caregivers to collaborate with each other across the different departments and even across geographies.

I see and I hear from my customers that there’s need for next generation. Everybody at this point is talking about population health management, which I think is the ultimate of workflow and analytics at the healthcare system level.

 

Along those lines, the work that GE Healthcare was doing with Intermountain was going to result in a lot of that, but they’ve moved to Cerner. What was the result of that partnership and why didn’t it continue?

The results or the intellectual property of the partnership today is to a large extent sitting into Caradigm. If I look at the models around clinical data structures, analytics, and protocol adherence type applications, all of that is in Caradigm.

The choice of Intermountain to go to Cerner, frankly I will not comment too  much on. It was essentially a choice on how they wanted to implement some of the intellectual property into their operation. The work that we’ve done over the years with Intermountain, the intellectual property, is sitting into Caradigm today, with many of the leaders that were on the project now in Caradigm.

 

Is GE Healthcare IT happy with Caradigm’s progress?

We’re very happy with Caradigm. Caradigm today is still, to a large extent, what we call the Caradigm Intelligence Platform. The ability to get to the data, wherever it is. Then you have the Caradigm analytics and the Caradigm population or care management suite of applications.

When we started Caradigm, we had all three components in mind. The first two go back to what we were doing with Intermountain. The population or the care management part, at that point already we were co-developing with Geisinger — care management applications for the Geisinger Health Plan. When we started Caradigm, we never gave too much visibility to it, although it was part of Caradigm on the formation of the company.

Over the past two years, much to our surprise and probably delight, the need for population health management has taken off way faster than what we assumed. We were well positioned. We have stepped up our focus on building out that suite of applications.

We’re very happy with Caradigm because it feels like we were at the right time in the right place in the industry. It’s very early days for population health management. We feel we have a very good and broad set of applications that enable population health management, from getting to the data to understanding your cohorts to setting up care management programs and linking into wellness and home health.

At the same time, when I look at population health today, there’s a lot of people who are claiming to have solutions. I consider 2014 and 2015 as the period where there’s going to be the selection made between PowerPoints and proof points. I see Caradigm as a company that will have the proof points. Everybody has the PowerPoints today. Over the next 12 months, we’ll figure out who has the real proof points of having solutions, analytics, and workflow that enable population health management and tremendous impact on the cost of healthcare.

 

Are your health system customers asking you to help guide them in operational improvement and population health management?

There’s a mix. I’m pleasantly surprised that many of the integrated delivery networks, which are the first ones getting on board, have brought on board people that have the right vision and the right capability.

My perception is that the need for consulting is lower than what I would have said three years ago. We bring with our technology the basic implementation consulting, but from a strategy consulting — how to set up population health management — I perceive most of the leading implementers today, having brought on board good people, smart people that know how to do that. Many of them have been experimenting. They now want to leverage technology to enable the rollouts on a broader scale.

 

What are the most innovative projects you’re working on that will come to fruition in the next two or three years?

We are very much focused at this point on building out our cloud capabilities, specifically in the imaging area. This is the area where we’ve leveraging to the fullest the new capabilities that GE has built in San Ramon.

At the last RSNA, we launched Centricity 360, a case exchange capability that complements our imaging capabilities. We’re further building out that case exchange capability to true collaboration capabilities that seamlessly enable institutions to collaborate together, to collaborate with affiliated and non-affiliated caregivers. First in the imaging diagnostic space, but with the technology, the platform itself is extendable to any form of collaboration. That’s one where we have the first betas.

At the next RSNA, we’ll come out with the next generation. It has the promise of bringing true cloud capabilities to healthcare and being a big enabler of allowing a very flexible way for caregivers to collaborate with each other.

 

Do you have any concluding thoughts?

On top of our vocabulary is outcomes. With your question on Healthymagination, what this industry needs is outcomes, not necessarily more technology. Specifically in the US, a lot of money has been spent putting technology in place. The industry has not fully gotten the outcomes for that yet in terms of productivity and quality. That’s where we’re focused.

At GE, we have the benefit of seeing different industries, also seeing how different industries have gone through different phases. I see today a lot of parallels in healthcare versus what I saw happen in airlines in the ‘90s. I’m 15 years with GE, all of it in healthcare. Before I joined GE, I was in other industries. It’s exciting to see that healthcare today is going through the same transition that other industries have gone through. Digitization and then using all that information to enable networks to operate as networks and to turn data into insights and better decisions.

I think the next 10 years in healthcare are going to be probably the most exciting ever. For those people working in the IT side of healthcare, it’s probably the best job in the world for the next decade, using technology to totally change the industry for the better.

Forums like HIStalk … the more we can enable and pump up people in IT to drive the healthcare industry, the more we’ll be part of something beautiful. This industry will not look the way it looks today 10 years from now. That’s a given.

HIStalk Interviews Eddy Stephens, VP/CIO, Infirmary Health

July 30, 2014 Interviews 1 Comment

Eddy Stephens is VP/CIO of Infirmary Health of Mobile, AL.

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Tell me about yourself and the organization.

I have been with Infirmary Health System for 32 years. I have a background before that in banking and in food service for a few years. My educational background is more related to accounting and operations research, back before people called it management engineering. I have been in IT for the greater part of my career, 35 years or so. 

Infirmary Health is a regional health system located on the Gulf Coast of southwest Alabama, in Mobile. We have locations in Mobile and Baldwin County, which splits the Mobile Bay, if you’re familiar with the Gulf Coast region, over the northern part of the Gulf of Mexico.

We have a 700-bed hospital which is our flagship, Mobile Infirmary Medical Center. We have a 150-bed hospital, Thomas Hospital, in a bedroom community in Fairhope, Alabama. We have a 65-bed hospital in the northern part of Baldwin County called North Baldwin Infirmary. On the campus of Mobile Infirmary, we have a long-term acute care hospital. We also have a Rotary and rehabilitation hospital that are both located on the campus of Mobile Infirmary. We have a clinic network of about 30 physician clinics, our largest being a multi-specialty clinic that has about 70-plus doctors in it, and it actually has multiple locations scattered around Mobile and Baldwin County. We have three freestanding diagnostic and surgery centers and are in the process of expanding our network out into a couple of other communities within the greater Mobile, Alabama area.

 

What’s the secret to being a long-term CIO?

I became CIO here about 14 years ago. I had come here as an IT analyst from a financial standpoint. I guess the secret is just trying to keep my head down and maneuver the politics of the system. It’s a great place to work and I have just tried to ingratiate myself to the team.

I’ve tried not to have a philosophy that said we’re going to use technology for technology’s sake, but rather see technology and the IT department as a service department. We’re here to serve the needs of the business and our business is healthcare. We try not to let the technology get in the way of doing what needs to be done.

 

Infirmary closed one of its hospitals a while back, saying the Affordable Care Act is requiring hospitals to reevaluate how they deploy resources. Including that, what are the biggest trends you are facing?

We closed that hospital. It was an acute care hospital in the west part of town. We relocated the long-term acute care hospital on that same campus to the main campus of Infirmary.

Because of the regulatory environment that we’re in and the change of healthcare, we see a shift naturally to population health management. To keep the patient from getting sick rather than just treating the disease.

We’ve already started that move toward a focus on wellness with our own patient population. We have about 5,500 employees in our own network. We’ve spent the last two or three years focusing on wellness and prevention of disease within our own organization. We’ve begun to reach that out into the community. We have external wellness programs that we offer to businesses. We’re seeing that taking shape.

I also see the hospitals becoming affiliated more — whether it’s through merger and acquisition or whether it’s through some kind of virtual affiliation — to where there are fewer primary inpatient acute facilities over time and more freestanding emergency room-type diagnostic centers that feed main campuses of fewer hospitals, rather than every little community having its own hospital like has been the case for 100 years in this country.

Population health management and wellness management are changing the way we look at IT and the service that we have to deliver.

 

What technologies do you use or expect to use with those new objectives of population health management and wellness?

We signed a contract with Epic back in 2008. We looked at Epic primarily because of the ability for us to have a single record across the continuum. That has served us well to this point.

It has taken some philosophical rethinking from where a physician’s office talked about having its own record, versus the hospital having its own record, to now having more of a patient-centered record. Where the record doesn’t really belong to one of those entities, even though it never really did in the first place — that was just a concept that we had.

Interoperability is going to be a big issue. In our city alone, every major hospital or health system has a different EMR vendor. Interoperability becomes an issue. Being able to share information with other agencies, rural health, those kinds of things. All of that feeding together in addition to communicating with payers so that we can have a complete picture of the patient.

Historically we have had our view of the patient and where the patient touched our system. For us to truly be able to be effective at wellness and population health, we’re going to have a more holistic view of the patient and everywhere the patient touches the healthcare system.

 

Are you getting Medicare claims data or other information from payers?

We are getting some. There is still a little bit of resistance in our world, because in Alabama, Blue Cross is the largest provider. They are also the Medicare fiscal intermediary. There’s still a lot of reluctance to share a lot of that information because of competition and other things.

I was just at a meeting where Karen DeSalvo was speaking here in Mobile. One of the things we talked about regarding interoperability is that we still have this mindset about competing from a business standpoint. We all view our data as somewhat of a competitive edge. Sharing of data is still philosophically a little bit of an issue in terms of how open and honest we want to be.

I see that in most of our medical staffs, even. Physicians are reluctant sometimes to share a lot of information with other physicians because of the competitive nature for the patient. “That’s been my patient, I’ve taken care of that patient, and I don’t want that patient to go down the street to someone else.”

Those things are changing. Some of those attitudes are changing. Some of the attitudes are ingrained from years and years ago. People are becoming more open and willing to share information as we see that, both from a regulatory and from a philosophical standpoint, you can only regulate to a certain point. Philosophically, people are changing their attitudes about how important it is.

From my personal perspective, I want everybody to know everything they possibly can about me if they have any inkling that they’re going to be involved in my care. A lot of people we encounter are not like that. This physician group was on Epic and our hospital was on Epic – a patient said they might not go to that doctor any more because of sharing of the information between those two entities. It’s a little bit confusing to me why some people think the way they do, but it’s a lot about the philosophical mindset that people have about their healthcare.

 

Other than your internal connections to the practices you own, how are you connecting Epic to the outside world?

We have almost as many non-owned clinics who have affiliated with us by installing Epic in their office through an arrangement with us as we do our own clinics. But we are also now working to share information with those physicians’ offices who may have Greenway or Allscripts or whatever in their office and did not want to go onto Epic because they already had an investment into a particular system, whether they liked it or not.

Also, under the safe harbor provisions of the Stark Law, there’s some things that I can do for a clinic who didn’t have any kind of electronic medical record versus someone who already had one that wanted to throw it out and put a new one in. We’re working that through our HISP and being able to provide CCDs, but we’re also talking about taking it to another level using EpicCare Link, which is a portal where we can provide certain level of Epic information outside to other people.

We’re also working with nursing homes to use the Kryptiq patient portal to be able to share information electronically. We’re finding that nursing homes do not have a lot of electronic health record information. For us to be able to move a patient out to that transition of care from the hospital setting to the nursing home, we’re looking at tools that we can provide to be able to electronically share that information with them. Even though they might not have a receptacle for that information, we can provide them a portal where they can securely access only the information that they need about their particular patient. We’re trying to attack it from multiple fronts, particularly as we try to meet Meaningful Use Stage 2.

 

Is anybody coming to you for an alert if their patient is admitted to your hospital or otherwise exchanging information for patients for whom they bear risk?

Some businesses are certainly interested in that, where they have a self-insured kind of situation. We do have some dialogue going on between different businesses and we are beginning to provide some of that service, at least from a wellness standpoint, which I think is the first foray into the population health management.

In the State of Alabama, Medicaid is trying to set up Regional Care Organizations in multiple regions throughout the state. We’re working in our region to see how that’s going to fit together. Huntsville Hospital is the main player in that whole region, almost having their own private RCO.  That kind of arrangement works well in our environment with Medicaid being spread across multiple facilities. There’s much more of a collaborative effort that seems to need to take place. We are having conversations among ourselves, the hospitals in our region, about how we’re going to be able to work within that RCO model with Medicaid.

 

How did you use speech recognition in your Epic implementation?

We have been a long-term user of speech recognition in some form or fashion. We Used PowerScribe for a number of years in the radiology area. We transitioned a number of years ago to back-end speech recognition in the medical records area. Subsequently we have gone to full outsourcing of transcription to Nuance. In our clinics, we had the traditional Dragon installed on a workstation with a PowerMic for many of our physicians.

As we begin to roll out CPOE and physician documentation into our hospitals at a required level, as in an “everybody’s going to have to do it now” situation, we were concerned about how we were going to get that progress note on the chart in a timely manner. We had — whether it was because of attitude, skill level, or technologically challenged — physicians who were used to either dictating some of the information and it showed up on the chart later or hand-writing in the chart. We knew that a progress note had to be an immediate action that appeared within the electronic record.

Some of them were challenged in using either NoteWriter within Epic or a template-driven kind of progress note. Many of them to this day don’t have any problem with typing or using a structured note of some type. But with a large percentage of our physician staff, we knew it was going to be a problem. They kept talking to us about how they could use transcription and how they could use dictation to be able to get their progress note on the chart.

Particularly at our two largest hospitals, we have a situation where most patients who are an inpatient at our facility have multiple clinicians following their care. There certainly would be a primary physician who is managing the care, but multiple specialists who might be involved in the patients due to the complications and co-morbidity of our patients. We knew that when Dr. A rounded, we had to have that progress note immediately available on the chart.

We were challenged with how we were going to be able to do that and also facilitate the needs of our physicians and try to make it as palatable for them as possible to transition from a paper record to a fully electronic record.

I saw Nuance’s SpeechAnywhere at UGM and purchased 10 licenses as a trial. I got my CMIO, who is a practicing rheumatologist as well, and a couple of other physician champions to try this. It worked extremely well. They began to show it to some of their peers and my 10 licenses were used almost immediately. We saw it as a way to get the progress note on the chart and to avoid the complaint that we don’t have enough devices for them to access.

Many physicians tell me they don’t do technology, but they have an iPhone on their belt and an iPad in their lab coat. They can use Epic’s Haiku application to pick their patients or for rounding or results review, so they could then pick their patient, dictate their progress note, review it, accept it, and then immediately have it show up on the chart. It was a home run for us. We have about 300 licenses active today.

It’s not for everybody. There’s a lot of people that would rather just sit down and type in their note or fill out a structured note template. But we have about 300 physicians today who are using SpeechAnywhere with the Haiku and Canto applications.

 

When you look ahead two or three years, what do you see as your biggest challenges?

The biggest challenge that I see for all of IT and healthcare is the onerous regulatory rules that we’re having to meet.

I’ve got a chart on the wall that shows all the things that have to be implemented by 2020. Regulations saying that not only do you have to provide a patient portal and lead that horse to water, but I have to force that horse to drink. It’s not enough for us to be able to provide that. The rules say that a certain percentage — and it’s fairly low right now, but I anticipate that going up — that I somehow have to engage the patient and make them use the technology. That to me is a little bit of a challenge — how we’re going to force people to use technology who just don’t want to use the technology. 

On the other hand, we talk about interoperability and we just say, “You just need to make it happen.” I’ve got Payer A coming to me and wanting me to do interoperability this way. Payer B wants me to do it this way. The hospital across town wants me to do it this way. 

You want me to make the healthcare system more efficient and you want me to drive cost out of healthcare, but yet you make rules that are nebulous. If you want interoperability in healthcare that works nationally like an ATM system in banking, the government is going to have to say, “Everybody is going to do it this way. This is the format and we’re all going to use it.”

It’s like HL7. HL7 is supposed to be the standard, but HL7 is not HL7 is not HL7. Everybody who uses HL7 wants to do it a little different way and add their own little nuance to it to make it somewhat proprietary.

That’s one of the big challenges that we have in moving towards this interoperability, Not only the philosophical and the attitude changes that have to take place, but making smart regulatory requirements. Let’s don’t regulate things that don’t make sense. Let’s regulate things where we really want to make things happen. By having a strict standard, we can actually accomplish interoperability.

HIStalk Interviews Linda Reed, CIO, Atlantic Health

July 28, 2014 Interviews 3 Comments

Linda Reed is VP of integrative and behavioral medicine and CIO of Atlantic Health System of Morristown, NJ.
 
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Tell me about yourself and your job.

I’m the vice president of integrative and behavioral medicine and chief information officer. I’ve been at Atlantic Health 10 years. For the first six, I was vice president and CIO.

About five and a half years ago, I got integrative medicine, which is massage, yoga, supplements, functional medicine, and acupuncture. Then about three years ago, I got behavioral health. One of my doctor friends here says, “Who did you annoy that you were able to get such a wide variety of things?” It’s funny because I tell the CFO here that I’m like the empress of everything that is expensive that makes no money. It’s interesting. My day is right brain, left brain.

I’m a nurse by background. I’ve been a CIO for almost 20 years. I just love what I do every day. I’m an activity junkie and this job really suits that.

 

How much of your IT effort is focused on plumbing type work like Meaningful Use and ICD-10?

I’d say it’s probably 60 or 65 percent.

We try really hard to do some other interesting things. We’ve put a lot of effort into mobile health. We’ve got a mobile health strategic plan. We just published a mobile health app. Taking a look at some interesting new and different kind of things to do with mobile health. We’re trying to spend a lot of time there doing a little more with telemedicine. There’s all this new, cool stuff you want to do, but you’re really anchored back in the ICD-10, Meaningful Use world.

We’re doing a lot of acquisition. We’ve added two hospitals in the last three and a half years and we’ve got one more coming at the end of December. They’re all different. One hospital was on a really old platform, not the one that we’re on, so we kind of ripped and replaced. The second one that we got had put some money into the platform that they’re on, so we decided to leave that one alone because they had attested. The third one that we’re getting is a little bit of both. They’ve got two different systems on the front and back end, so we’re still looking to see exactly how that one’s going to transition in. We just went live on Tuesday with a brand new ambulatory system for our physicians. It never stops.

 

Which ambulatory system did you go live on?

Epic ambulatory.

 

Are you still primarily a McKesson shop?

Yes, we’re still McKesson.

 

They’ve sent some mixed signals about their healthcare IT direction. How do you see that playing out?

Their direction is Paragon. The hospital I said that had a pretty good platform that we left in place is Meditech. 

We belong to a consortium called AllSpire. That is us, Lehigh Valley, Lancaster General, Hackensack Medical Center. Of the seven members, four are already on full Epic.

We know the direction McKesson is going with Horizon. We’re going to have to make a decision in the next couple of years as to where we’re going to go. We know we’re not going to stay on Horizon.

My job is to try and give the organization options. When you take a look at what’s going on in healthcare and you start looking at the trajectory of hospital buy-ins, can you really justify a huge expense?

 

Nobody goes ambulatory Epic unless they’re going inpatient as well. Isn’t that predetermined?

I don’t know. I’m not really sure. Before we did this, I talked to a number of consulting companies. How much cross do you have between the people that come into your ambulatory and are in the hospital? How much back and forth do you really need? Could that be done by a summary of care, CCD, and CCDA? I’m not sure — that might be.

We’ve got a direction we could take, where we have like-for-like licenses because of all the investment we’ve made over lots of years. We’ve got an option for an integrated platform that already exists in one of environments — it might be something we want to do. We’ve got a third option that we’ve already got the ambulatory component in, and then if we wanted to work with our partners in our coalition, we could do that. What I’ve tried to do is try to give Atlantic Health multiple options to choose from.

 

What do you think the driver will be as to which way they go?

I think it will be looking at where we are from a volume perspective, where we want to be on the risk side, how much we want to manage what we have.

We’ve got two accountable care organizations. If we do a good job in that realm, aren’t we going to be driving patients out of our own hospitals? If we do that, we want a really, really robust ambulatory system along with population health management, analytics, and care management tools. How big does the hospital system really now have to be?

 

Have you looked at any of those technologies for ACOs, population health management, and analytics?

No. We stepped in gingerly. We took our time. We tried to use what we had in place.

We started off with RelayHealth. We’ve been a big user of RelayHealth for many years. RelayHealth provides the platform for our regional health information exchange. We’ve got 30 hospitals on that here. We started off with that, and then we moved into some business intelligence. We have MedVentive for population and risk management. McKesson does a lot of work in the payer space for disease management, so we’re working with them right now on putting in their care coordination tool.

We spent a little time understanding what it is we needed to do, then tried to put a few technologies in to be able to do that. We’ve got the business intelligence. We’ve got to work on the care coordination tool — that’s next. We’ve got Relay to do some of the health information exchange.

We use Imprivata Cortext, a secure texting tool. We’ve built specific directories for the ACO physicians so that they can now use that as a secure referral tool for each other.

I’ve been a customer of Imprivata in multiple organizations. They’re an easy company to do business with. I’ve used their OneSign. Our doctors love the tap-and-go because they all have their little card and their one workstation. They don’t even log off, they just tap. It closes the screen and they tap it again wherever they go — it brings up their session wherever they are. They just love that. We started using their secure texting about a year ago.

 

They’re using Imprivata Cortext it as their communications clearinghouse so they don’t have to play phone tag? They just send the text message and walk away?

That’s right. Our ACO put together a per-member, per-month incentive for physicians up front so the physicians don’t have to wait until savings at the end of the year. There’s a number of different sections there. There’s one for the use of technology. If they use RelayHealth, if they use Imprivata Cortext, if they automate their offices, they get a certain amount of money. For some process measures, they get it. For some outcomes, they get it. There’s a couple of other things. Their whole per-member per-month incentive is based on certain activities that they do.

 

I assume you need to analyze your data across the Epic on outpatient and McKesson and Meditech on inpatient. What are using for a data warehouse?

We use Horizon Performance Manager. The pop stuff all comes out of MedVentive. MedVentive has data from the EMRs, from the HIE, and whatever they might need from the hospital.

 

Are you looking at any technologies that can help support the clinician-patient relationship and patient engagement?

Our app is a patient-facing app. We’re constantly working on we help physicians and patients communicate.

A number of years ago, we put in RelayHealth, which had secure messaging with physicians. I had one doctor say to me, “ I will never, ever, ever, ever trade an email with a patient.” Then about a year ago, she came back and she said, “That’s not so bad.” She was telling another doctor, too, “I talk to my patients on email all the time.” It’s really interesting to see the dynamics. I think we’re probably going to be looking at doing something very similar on the mobile front.

 

Tell me about the mobile app.

It’s called Be Well. We have one for each one of our hospitals, because our physicians are more specific to our geographic area. It’s got a physician directory, ED wait times, and a whole bunch of different health trackers, including a way to download your Fitbit information.

 

Did you develop that yourself or have it developed?

We worked with a company called Axial Exchange. Everybody today will tell you that it doesn’t make any sense to go out and do that kind of work yourself when there’s just so many other companies that you can work with. 

There’s a health encyclopedia in there, but it’s the same kind of health encyclopedia we use on our website. For us, now we’re migrating from the web to mobile. That’s where we’re going there.

 

As a nurse, do you think nurses are underserved as far as technology that helps them do their clinical role rather than just documenting so that somebody else can send a bill or have the doctor read their notes?

That’s an interesting question. We put in Vocera a lot of years ago now. One of nurses’ biggest issues was the phone tag that they were playing with doctors. They don’t all carry around organizationally-provided smartphones. From an access to information, it could be more helpful if they did.

 

Do you discourage them from using their own?

We don’t. We do discourage them from SMS texting on their own. It is one of the reasons why we went out and got Cortext. Just telling people not to use SMS text and not giving them something to use makes no sense. It’s like spitting in the wind. 

The interesting thing about nurses is that we’ve got those computers on wheels. They’re on those things all the time. To take them off takes them out of their work flow. The Cortext component has a PC-based user interface, not just mobile. You can be on the COWs or you can be on the mobile.

Right now for nursing, I think it’s moving in that direction. I just don’t think that it’s quite as mobile-enabled as some of the physician tools right now.

 

What are the organization’s biggest strategic issues that need IT help?

Care coordination is huge. We’re kind of schizophrenic because we still are fee-for-service and we still are doing procedures and patient care in the hospitals, but we also have these ACOs. While we still need to be able to get people in and have great turnaround time, decrease the length of stay, get more turns in as much as we can, on the other side, we’re still working on how do we keep people out of the hospital and in the ACO and keep and have that gap and address all the gaps in care and the transitions of care? 

It’s like two different initiatives that we’re working on. We still have to keep the whole patient engagement and satisfaction thing going on the other side.

One of the things we did a few years ago –it’s on paper and we’re just getting ready to take a look at how to automate it — is we had created a patient itinerary report. One of the big things that patients always complain about is that they don’t know what’s going to happen to them during the day. We created a report that pulled it from different parts of our technology — what’s the patient’s name, why are you here, when did you get here, who are the care providers on your case, what medications are you on, what labs did you have ordered for you, what were the results of the labs that you had yesterday, are you going for any other tests? Then there’s a little spot for “questions to ask my doctor.” That really was pretty popular and the patients seemed to like that. We’re probably going to automate that. 

One of our next ventures in the mobile space is probably a bedside app that would give you that whole access to “my care team, my itinerary, my meds.” We also have that on our TVs right now, but we’ll look at putting it on an iPad.

 

Most hospitals would use an interactive patient system approach and put it on the TV, but you’re going to give patients iPads. Has anyone done that?

No. There’s a couple of places that are looking into doing it. There’s also a company out there called PadInMotion. They do some of that and they also give patients access to like Netflix and things like that on the iPad. 

The more of this education stuff that you’re going to put in front of patients, a TV on a foot wall is really a tough user interface to give patients unless the thing is like 120 inches. I don’t know how big the screen has to be. Giving them an iPad is probably a good way to do that, but again, we also have to take a look at the patient population. When my dad was in the hospital, he could barely work the remote control on the TV, much less an iPad. It’s just trying to meet the needs of the patients that are there. You have to have multiple user interfaces to help patients through all the technology we throw at them.

 

Physicians are moving, or moving back, into leadership roles in health systems. What advice would you offer nurses who want to move into leadership roles outside of nursing?

Don’t say no to anything. I have a job today that practically didn’t exist when I first started in my nursing career. Take on any opportunity. 

The one thing that sometimes you see with nurses is that they like to have things that are very concrete. It’s interesting because we work on the fly every day. We are the leaders of multitasking. But sometimes I think having a job that doesn’t have a very concrete job description or isn’t very clear on the time or the hours or the responsibilities — I think they shy away. They don’t realize how freeing a job that’s maybe not quite baked can be, because you can bake it yourself.

Nursing is also very isolating because you’re in those nursing units all the time. Sometimes you don’t get a lot of opportunity to meet and speak to board members, meet and speak to senior leadership. You’re just tucked away enough that you’re not exposed. That’s the other thing–say yes to any committee. Get out of the nursing unit and get some exposure.

 

Do you have any final thoughts?

For anybody who’s in a hospital and just thinks of healthcare as a hospital, where we are going should be frightening to you. We’re not going to be a hospital, especially if we start taking a look at the people who are going to disrupt us the most — retail medicine. 

We have to start thinking about ourselves as the providers of retail medicine. We have to think about fast access, customer service, the customer’s always right — those things that you’ve traditionally heard about retail environments. We have to stop thinking about healthcare as a civil servant-type environment where you call and you get an appointment four weeks later. It’s going to change everything we do. We’re going to have to get faster, better, and more consumer friendly very quickly.

HIStalk Interviews Amy Abernethy, MD, PhD, Chief Medical Officer, Flatiron Health

July 21, 2014 Interviews 3 Comments

Amy Abernethy, MD, PhD is SVP/chief medical officer of Flatiron Health of New York, NY.

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You’re going from ivory tower research and patient care to work for a start-up run by a couple of twenty-something Internet millionaires who have no healthcare experience. What do you hope to accomplish at Flatiron Health that you couldn’t do at Duke?

For the last decade or so, I’ve been working under the basic premise that a fundamental challenge in better bridging research and clinical care was the lack of interoperable or real-time data. I’ve been working on this problem from every direction, usually with cancer care and research as my demonstration model. Sometimes my approach was to focus on how to create the data stream. Sometimes I focused on cyber infrastructure. A lot of other times, my focus was from the point of view of, “If you have the data, what would you do with it next?”

In this vein, I thought about the context of clinical use as well as other problems like storing the information for research, quality, etc. in the future. It has been clear over and over again that a key bottleneck to solving the problem has been in creating the right kind of data infrastructure that is large enough and represents a broad enough footprint of the whole population.

About a year ago, I started learning about what Flatiron was trying to do. It’s interesting the words that you described, “Internet millionaires who didn’t know anything about health IT or healthcare.” That’s exactly where I was when I first started talking to them. They would call me and I would give them a hard time on the phone, and then otherwise that was the end of the conversation. But every single time I said to them, “OK, here’s what I think you need to solve and here’s what I think you need to do next,” and then, a month or two later, they would call me back up and they had done it.

Over the course of about six to eight months, they advanced a series of what I thought were critical steps to solving this problem, at least within the cancer space. By March, the convergence of those steps got me to the point where I said to myself, ”If I’m going to truly work on this problem, solving it and taking it to the next level, then I need to not be watching from the ivory tower, but right in the middle of it. I need to help lead it forward.”

 

It sounds as though you’re buying into their premise that oncology needs to be disrupted.

I am absolutely buying into that premise. From the standpoint of being an oncologist, I have sincerely believed that it needed to be disrupted for a very long time. But I feel like I have been playing around with how to disrupt it and have been more nibbling on the edges rather than getting into the center of the story.

As this year has progressed and I’ve been talking more and more to Flatiron, working with important groups like the American Society of Clinical Oncology, laying out a roadmap for learning healthcare, etc. it became clear that solving this problem was part of the major disruption action.

 

Oncology is more patient-centered and longitudinal in treating patients for years. In your TEDMED talk, you talked about using data both from providers and from patients themselves more effectively. How do you see all of that feeding together and what’s the patient’s role in creating this data?

I’m going to take that question into two parts. On one side, I’m going to talk a little about why I think oncology is a unique space, then also talk about what I think the role of patients is.

From a standpoint of oncology being a unique space, in 2009 or so there was a paper in Health Affairs by a guy named Lynn Etheredge that set out the premise that if we’re going to solve the Medicare dilemma — in other words, making Medicare sustainable — we need to attack it from the point of view of oncology. My point is that I’m not the first person to say what I’m about to say, but it has started to crystalize and become clear over the last three to four years.

Oncology is unique because of some of what you said, which is there’s a longitudinality to it. We follow patients very intensely and have very close connections over time. It’s also a space where the science and the clinical care meet.

If you want to solve problems in learning healthcare where the science is as visible and as expected to be a part of the clinical space as the rest of clinical medicine, oncology is a good place to do that. Its a place where the conversation around a patient being involved in clinical trials is a given, not an extra conversation on the side. Then there’s an inherent urgency to cancer care and research; an inherent patient and family centeredness to it.

Then, frankly, it costs a lot of money. The expense of cancer care is going up both because it’s now becoming one of the dominant causes of death, if not the leading cause of death, worldwide. Interventions are getting more and more expensive.

We’ve got this confluence of reasons that make oncology a good use case, a demonstration model. It’s not the only place we’re ultimately going to need to solve this problem, but it’s a good place to start.

The other question that you had was something that I really believe in, which is that patients shouldn’t be a sideline in the story, but need to be central to the story. When we talk about learning health systems, it’s as if the unit of goal optimization is the health system itself. But shouldn’t it be that we’re optimizing healthcare because it’s better off for people and for patients? Instead of optimizing healthcare so that the hospital makes more money or the health system is financially sustainable, let’s focus on better care for patients, with improvement of the health system as a byproduct. That’s a much better model.

I always start off my thinking about how to tackle these problems with the patient at the center of the model. An interesting thing happens when you do that. One of the big issues in learning health systems is data linkage — the ability to take care of populations, the ability to follow people longitudinally over time. When you center the conversation on the patient first, it is much easier to think about how to solve some of those problems.

I have found that by disrupting even our way of thinking about learning health systems so that the patient is the central unit of what we’re thinking about as opposed to the health system being the central unit of what we’re thinking about, we approach solving a lot of problems much differently and smarter.

We’re also in an interesting place where the kind of data sets that we’re going to have in the future aren’t just going to be, for example, electronic health record data or administrative data. It’s going to be data generated by patients, by people, wherever they are.

I started off doing this work in patient-reported outcomes and thinking about how we ask about their symptoms, their quality of life, what is meaningful as it relates to health and healthcare. It turns out that technology enables us to imagine a world where you can ask a patient about symptoms sitting in the clinic waiting room or you can ask about symptoms when the person is sitting in their home in Asheville, North Carolina. You can follow people in between the visits, etc., gathering a much clearer picture of the longitudinal story and implications of different health interventions. 

The land of patient-generated data is getting more and more interesting. The ability to use biometrics and sensors and understand what our world looks minute to minute and day to day from an individual person viewpoint really changes the landscape of how we use big data to solve problems in healthcare. The ability to think of glucose data not just as a data point being generated by the hospital lab, but as glucometer-based data that’s coming from the home.

We’ve been collecting these kinds of data for a long time. The home glucometer is nothing new. Pain became the fifth vital sign in the 1990s. But we haven’t really systematically thought about how this is a part of our national data set in order to solve the problems of learning healthcare. When it comes to patient centricity, it shouldn’t just be a byline, but part of the way you think about designing and developing our systems.

 

When people think of oncology data lately, they’re probably thinking about applying genomic information to treatment decisions or sharing protocols from major cancer treatment centers. How do you see all that fitting together, particular on the genomics side?

The genomics side again is a really nice use case. I don’t think you or I believe that genomics is going to be the only scientific story in the future. There’s going to be a lot of other ones. But if we can start to get our head around how we merge what’s happening within the context of life sciences and basic sciences with clinical annotation of basic science data putting biological discoveries into context of what happens for individual patients, our science will be much better.

Those two pieces need to come together. In order for that to happen, we need to do a lot of things. One is we need the cyber infrastructure that allows that to happen. It’s the combination of bioinformatics as we’ve classically thought about it plus clinic informatics and applied informatics and the emerging combination of these, including dealing with everything from the storage, data quality, and data use issues. Also starting to think about how much information do you really need to store for this particular patient, how do we analyze it, what is the right research to conduct, and what should that look like.

Another example of what we’re going to need to deal with is trying to get our heads around if we did have a cyber infrastructure, how do we thoughtfully manage the security, confidentiality, and privacy issues? If we are bridging between questions in clinical research and healthcare quality, how do we deal with questions of permissions, consent, and human subjects protections? These pieces are starting to crystallize, but we have a long way to go.

The genomics use case also takes us into the clinical applications side. As we start to have more genomics-informed cancer care, for example, how do we help clinicians and patients make snap, very quick, well-informed decisions at point of care so that we’re surfacing in real time the right combination of this person’s genomic profile, coupled with what we know are the right drugs for that particular clinical scenario, and understanding that there are limitations to what’s possible depending on reimbursement scenarios? It needs to be the complete complement of data in order for clinical decision support systems to be truly useful and not annoying. As a very basic example, if we surface genomics plus drug information independent of reimbursement, we’re not doing anybody any good.

Ultimately, solving these problems for genomics and, along those lines, next-generation sequencing, within the context of cancer care, presents us with a great use case that’s going to be replicated multiple times.

 

Oncology is a lightning rod is from a societal perspective. Hospitals that suddenly start treating oncology patients as outpatients because they mark up their visit higher than oncologists in the office, for-profit cancer chains, oncologists paid to administer or incented to administer more expensive drugs, a lot of pharma influence, the pharmacoeconomics of expensive drugs versus what benefit the patient gets. All those are issues interfere with the pure science and medicine of how cancer is treated. Do you see that being something that Flatiron will help resolve?

This is the reason why data is the bridge. All of those problems have as a foundational or fundamental underpinning — the need for discrete, interoperable data that can be reused to address each of those things simultaneously. Whether or not you’re actually trying to get the science smarter or you’re trying to optimize reimbursements, you need essentially the same data points to do so.

One of the reasons that I made the jump from academia to industry is to try and figure this out. Resolving all of these problems means that first you’ve got to deal with the data bottleneck. But at the same time, you need to be doing R&D work, imagining a world when the data bottleneck is solved and answering the question of “and what do I do next.” You have to be ready to work through all of those different, as you said, lightning rod questions, which is going to take a lot of work and practice.

While ultimately the data are substrate and producing the data streams that can be analyzed to solve those different problems is a fundamental underpinning, after that you still need to advance the work in the analytics space, align culture, sand out processes including scientific methods in order to pull all of the pieces together, etc. I have this one talk that I always give on the convergence of personalized medicine, comparative effectiveness research, healthcare quality, healthcare optimization, and patient centricity. If you take all of those, the one common element is interoperable data.

 

Along those lines, along with the announcement of the Google Ventures investment in Flatiron was its acquisition of Altos Solutions and its oncology EMR. Was that done as a way to get quick access to a lot of oncology information without having to do individual integration with the varieties of EMR systems that are used by oncologists and hospitals?

There’s a couple of pieces of an answer here, so I’m going to take it separately. First of all, the way that Flatiron is doing its work is EHR independent. The idea is essentially to extract the data from the back end use a process of technology-enabled chart abstraction and other techniques to make it to a common data model. This dataset can then be integrated with other data feeds like the Social Security Death Index. It doesn’t matter if it’s Varian or iKnowMed or Epic Beacon from an oncology EHR standpoint.

The addition of Altos revved the engine, because at least now there’s one cloud-based oncology EHR that has essentially a single instance and doesn’t require a different setup for every single site. But is really essentially one additional extraction to an overall model. That’s the first point of efficiency.

It also catalyzes or adds a jump to the next level in terms of acceleration of footprint for the number of oncologists and therefore their patients represented in the national footprint for Flatiron. Those two things are important and near-term wins for why Flatiron bought Altos, but now you’re going to hear Amy’s part of the story.

If you take what I just said — and I love the way you said it was a lightning rod – oncology is a lightning rod for all these pieces coming together, not just solving the science and genomics, but it’s the comparative effectiveness research, figuring out how to optimize healthcare, etc. As I mentioned, data is the fundamental substrate, but then you have got to learn what to do with it next.

A lot of that also is clinical decision support for personalized medicine and other interfaces directly in the clinic at the right time with doctors and patients to make healthcare more efficient, patient centered, and of better quality. For example, better allocation of care along predefined evidence-based pathways and monitoring of whether the care provided actually aligns with the evidence. The availability of real-time education.

Altos as a cloud-based EHR will provide Flatiron with a beautiful, national scale living laboratory to try out all the different ways of using and reusing data in the context of what EHR can do for you. It’s a near-term win in terms of data sets and efficiency, but the real big win here is in terms of a national living laboratory where Flatiron and clinical partners can work together to use technology tools to make cancer care better. Now that’s a use case.

 

Other than that acquisition, $130 million is a pretty big investment for a startup. How will that money be used?

A key aspect of the focus of Flatiron for the next two years or so is going to be making sure that the corporate philosophy is well attended. This includes building the tools that are needed, making sure that clinical practices are well served in terms of having their data extracted and getting them meaningful processed data back that’s actionable at point of care, and the scale from the technology development side in order to support key data partners like the life sciences. We need to ensure that this happens efficiently and with the right kind of engineering focus. That’s going to be a big piece of it.

There’s also ongoing work on how we surface this information, optimal data visualization solutions, how to help clinicians and practice administrators understand the information as efficiently as possible, how do we optimally interface with patients. There’s already a current product, OncoAnalytics, that allows practices to see their data in a dashboard format. It’s really good and certainly much better than anything they’ve already got. But how do you really rev that engine up for data users of all types? That’s going to be a place of substantial investment as we think about how we can get more and more information to practices, life science partners, health systems, researchers, professional bodies, etc.

Why is that so important? We need to see all users of the data, doctors and patients and health systems and sponsors, as key constituents. To create a national data set, it needs to be sourced from many, many places and those different contributors need to see value as to why they want to keep participating and contributing. And it needs to be used. Data quality improves when data are used, not hoarded. Servicing those places is a critical focus.

 

Do you have any final thoughts?

One of the things that’s been interesting to me and for me is personally making this jump. I haven’t left academia entirely. I still have a 20 percent footprint at Duke, which I maintain so that I can keep working with clinicians and others on solving the problems that we will be able to solve when the data bottleneck is resolved, on mentoring, on other aspects of R&D.

While it’s clear to me that Flatiron is the right vehicle with the scale and talent needed solve this data bottleneck, it was also important to continue to develop the future talent that will be needed to support the next steps in the vision. That’s where my Duke job comes in. Academia offers a unique place for growing the next generation. We all must keep our eye on the big vision, hammer home hard on the key tasks that have to be sorted out, and prepare for the exciting future.

HIStalk Interviews Susan DeVore, CEO, Premier

July 14, 2014 Interviews No Comments

Susan DeVore is president and CEO of Premier, Inc. of Charlotte, NC.

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Describe what Premier does, especially with regard to healthcare IT and data.

Premier is, I think, the largest healthcare improvement alliance in the country. We are integrating data from hundreds and thousands of hospitals on our platform to solve the cost, quality, safety, and population health or outcomes problems.

We’ve got a 59 percent footprint. We’re serving 3,000 hospitals in various ways. We have about 110,000 non-acute care sites. We have insights with data on one in three patients in the country.

It’s a massive business intelligence platform that we’re wrapping around services and capabilities to help these healthcare systems transform from the inside.

 

Premier was a hospital group purchasing alliance and is now a publicly traded informatics company that offers solutions for supply chain, labor management, population health, and quality. How does that all fit together to help hospitals as payment models change?

We’ve been building these data assets and this supply chain capability for a long time. Over the last three or four years, we’ve fundamentally rebuilt our entire foundational infrastructure. It was clear to us that all of these one-off solutions and individual vendor solutions aren’t going to solve the complexity of healthcare problems.

We decided a while back that providers needed to be able to connect the data, have the business intelligence come from all vendors and all payers, and be normalized and cleansed and standardized. We needed a social business capability on the front end so that we could accelerate the best practice sharing, content review, and knowledge transfer among these healthcare systems. We decided this was going to be the only way you could really solve the cost, quality, and outcomes problems.

 

As a provider, knowing where you stand in the continuum and not just how well you improve on your own is a pretty big deal. Will vendors struggle to compete as the market finds that their single tools may not offer enough?

The problem for any single vendor is that they only have a piece of the picture. Even EHR vendors. In our mind, they’re only one system of probably 12 or 13 different sources of data that you need to solve the problem. Any one payer that tries to solve the problem, or comes from a payer, has a view into only the payer population.

When we set out to do this, we said, we’ve got to be vendor agnostic and we’ve got to be payer agnostic. Health systems want to change the way patients get cared for, regardless of which EHR system they use or which payer they have a contract with. They want to change the way care is delivered for a patient population.

We think it’s a differentiator. We think that it will be critical that vendors are required to make their information exchangeable and not require that our health systems have to pay every time they want to make the information exchangeable.

 

How do you see that happening? It’s been a sore spot with providers that systems are supposed to be interoperable, yet they often aren’t unless you write a check and probably accept less functionality than you want.

I think there are three things that are going to drive it. The first is that providers are going to drive it, a coalition of providers who need the information to be more effective at what they do. Providers are increasingly dissatisfied with the lack of the exchangeability or the interoperability, so I think they’re going to require it.

Secondly, I think consumers are going to require it. Consumers are going to say, I need to make the decisions. I need the transparency to the information. I want it.

Thirdly, we need policy change. The thing that will accelerate it is if policy makers start to realize we can’t solve the cost, quality, and outcomes problem in healthcare without it. Those three things could push it faster.

 

Hospitals are trying to figure out what role they will play in the retooled healthcare system. How can information help them determine their business model?

Because we have this 59 percent footprint and we cover basically every geography, we see health systems that have been morphing now for several years. They have affiliated physicians. They have affiliated nursing homes. They have partnerships in the community. They’re building virtual IDNs, virtual ACOs, real IDNs, and real ACOs and have been for a long time.

They also usually have in those community markets more sophistication, maybe, and more capital to help build the integrated capabilities and to help access the integrated capabilities.

From our perspective, if and when the healthcare system moves to a more bundled payment world — whatever form that takes — this integrated data is going to be extremely important. It doesn’t have to all come from the source system. Many of our health system’s big IDNs are saying, do I really have to switch everything out? Or in an open data, big data, cloud-based, shared infrastructure world, can I find ways to go get the data and put it together?

These health systems are going to be an integral part of what healthcare looks like in a future state world. They’ve been starting to build this capability and put these pieces together for a long time.

If the pie gets bigger for our healthcare system, and they have a lot of pieces as opposed to one singular hospital piece, I think this is a pretty natural evolution.

 

Are providers jumping too quickly into ACO arrangements?

I think they’re experimenting with ACO models. As opposed to jumping all in, they’re trying it on a population. They’re now receiving data from CMS, which was something healthcare systems had never historically been able to do. They’re learning a lot. They’re figuring out how to manage the provider risk.

What we say to them, and what they say to us is, we’re trying to future-proof them and they’re trying to future-proof themselves. Whether it’s an efficiency measure that is measuring cost three days before acute care stay and then post, a bundled payment program, an ACO, or Medicare Advantage — if you’re able to connect data and you’re able to turn that data into business intelligence, pulling it from all vendors and all payers and putting it in the hands of your providers and change the way care is delivered, then there may be multiple models for a while we’re in the transition. That infrastructure is going to position you to navigate through those various models.

 

How will it be different for an academic medical center versus a community hospital?

They have different challenges. Community-based systems are integrating physicians very significantly. They have to have data and connected information in order to influence the practice of medicine.

In an academic center, you’ve got a more employed model that you can deal with, but you have other challenges. How do you fund research? How do you fund all the other activities and pay for and compete in the community healthcare system?

We have them all. We have academics. We have small. We have large. We have big IDNs. Some of our academics will tell us it’s easier for small community systems to drive change. Our community systems will say it’s easier for academics because they’re larger with more funding and more resources.

The truth is, this is performance improvement. You need the data. You need the data connected. You need to operate and change your operation. Whether you’re an academic or whether you’re a community health system, we can see the change happening in both and in neither. It has more to do with the culture, the measurement, the data, the infrastructure, and the willingness.

 

You’ve suggested the possibility of acquisitions. What areas interest you?

We report publicly in two segments — a supply chain segment and a performance services segment, which is where all of our HIT assets, informatics, and consulting and collaborative activities are.

We have said, and continue and to say, over on the performance services side, we are interested in ambulatory data acquisition and connectivity of ambulatory data to acute care data. We’re interested in all kinds of population health and data analytics technologies and capabilities for our members to build this population health capability. We’re interested in major things in both of those buckets.

We’re also interested in the area of patient-reported outcomes and in the implementation of standardized, more cost-effective, clinically-effective healthcare. We’re looking at all kinds of things in those areas.

On the supply chain side, we think there’s still a ways to go in changing supply chain capabilities in healthcare systems. We’re looking at workflow kinds of capabilities, alternate site capabilities, and the connectivity for supply chain between all the alternate site locations and the hospital or health locations. We have a specialty pharmacy. We think it’s a critical element to population health, so we have some interest there also on the supply chain pharma side.

 

Do you have any final thoughts?

It’s a very dynamic time. Integrated information that’s vendor agnostic and payer agnostic is critical.

Health systems have spent hundreds of millions of dollars installing EHRs. They’re increasingly dissatisfied with the inability to exchange information. They’re not so interested in spending hundreds of millions more to build data warehouses.

We think there’s a real opportunity for shared infrastructure and shared integrated data management capabilities. We are making significant investments there.

An HIT Moment with … Joe DeSantis

July 7, 2014 Interviews 4 Comments

An HIT Moment with ... is a quick interview with someone we find interesting. Joe DeSantis is vice president of HealthShare Platforms of InterSystems of Cambridge, MA.

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What interoperability benefits do healthcare organizations seek beyond just connecting systems, and what progress have they made?

First off, I think it’s important to say what we mean by interoperability. At the most tactical level, it means you can pass a clinical document from one system to another.

We think of it as something much more strategic to the organization. Sharing all health information, including financial and operational data, to achieve strategic objectives. If you have a platform that can view data as discrete elements and not simply as documents, you can support advanced analytics, decision support, rules, and other use cases. With robust connectivity, you can use your data in real time within the context of your existing workflows. And you have a foundation for creating new applications that work together and extend the capabilities of the entire system.

Our customers use our health informatics platform, called HealthShare, to achieve strategic interoperability and create an infrastructure of connected care solutions, not just to address their current challenges, but those that haven’t yet emerged. For example, North Shore-LIJ, one of the nation’s largest health systems and the largest in New York State, has harnessed strategic interoperability to improve care for its obstetrical population. This includes information sharing and care coordination among more than 100 providers, three outpatient EHRs, two inpatient EHRs, and two prenatal imaging centers. They share a coordinated record, dynamically identify members of the high-risk pool, and use alerts to notify providers of gaps in care. And, for a rapidly growing health system, North Shore-LIJ knows the platform can support its long-term needs.

On a regional or national level, strategic interoperability is essential to public health management. One statewide health information network, built on our platform, was able to reduce the time needed to report on a regional disease outbreak from several months to a few hours.

 

Describe the relationship between interoperability, population health management, and patient engagement.

Population health management and patient engagement are long-term goals for healthcare organizations. Both concepts are relatively new and important. They both offer the promise of helping to address the enormous issues related to chronic and lifestyle-related health problems. Neither is well defined yet.

Interoperability, or more importantly, strategic interoperability, is also a long-term goal. It differs from the others in that no one is really interested in interoperability for its own sake. They are interested in what they can do once they have it.

Population health management is about understanding the entire community served by your healthcare organization, not just the patients you have encountered. It is not a one-size-fits-all problem. There are no true off-the-shelf population health management applications. Instead, there are extensive services you can buy under the guise of a product.

The best approach to population health management, in my opinion, is to think of it as a collection of smaller, interlocking issues. The solution will be to deploy a number of focused applications, some from vendors, some custom built. These applications will need to work together and be integrated within the existing health information systems and workflows. This is why you need strategic interoperability to address this problem.

Patient engagement is about giving patients the tools to take charge of their own health. Again, strategic interoperability plays a big part. If you can provide a complete view of the patient’s information – not simply regurgitating test results from a single EHR – and if you can make services available to the patient within this context, like making appointments, education, communicating with providers, then you have something of value to offer your patient community. And coincidentally, you have a component of your population health management solution.

 

How is HealthShare different from other HIE, integration, and analytics solutions?

HIE, integration, and analytics products are, in general, single-issue solutions, each requiring separate management and often its own database. These solutions proliferate within organizations, ultimately contributing to information silos rather than addressing the fundamental challenges of healthcare.

HealthShare is above all a unified software platform designed for information sharing. The platform provides three important capabilities. It gives the ability to manage and store all kinds of data – relational, object, XML, unstructured – in a reliable, efficient, and interoperable manner. It provides connectivity – applications to applications, applications to users and devices, and users with communities. It provides insight, through analytics, as an embedded part of the entire platform. This gives our customers the ability to solve big problems.

One of the other key differentiators between individual solutions and a platform like ours is that once an organization adopts HealthShare, they have almost limitless growth options and multiple paths to success. They can implement a robust application module such as our Clinician Viewer. They can build out their own applications. And they can purchase HealthShare-based solutions from our many software partners.

 

What types of alerts are possible?

We refer to alerts as smart notifications, and again, the possibilities are nearly limitless. Because HealthShare aggregates, normalizes, and enhances all kinds of data in near real time, alerting capabilities are only bounded by your user base and your data investment.

Sometimes the simplest alerts offer the most rapid return on investment. For example, In Rhode Island, primary care doctors receive smart notifications when their patients are admitted or discharged from the hospital so they can properly manage care after discharge. They’ve measured a drop of more than 16 percent in 30-day readmissions for patients whose doctors subscribed to the alerts.

 

Many companies are selling analytics solutions. What factors will make specific vendors and their customers successful?

We have found that organizations that follow four important steps – capture, share, understand, and act – are more likely to achieve breakthroughs. Your organization first needs to capture health-related information. Then you have to share this information in a meaningful way among systems, applications, providers, organizations, and communities. The data, both structured and unstructured, must then be analyzed and understood.

Then you are ready to act. You can use the results to drive transformative action within your organization. For both vendors and customers, these four steps will be critical to success.

HIStalk Interviews Davin Lundquist, MD, CMIO, Dignity Health

June 25, 2014 Interviews 1 Comment

Davin Lundquist, MD is VP/CMIO of Dignity Health of San Francisco, CA.

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What systems are you using on the ambulatory side and what are your priorities there?

In California, we have laws that prevent corporations from hiring physicians directly. The structure that Dignity Health primarily uses in California is a medical foundation. We have Dignity Health Medical Foundation, for which I practice at one of their sites in the Ventura market. Camarillo, California specifically. I’m a family medicine physician, a PCP. 

In our medical foundation, which has about 600 physicians plus several hundred radiologists, we use Allscripts Enterprise for our ambulatory EMR. Dignity Health has nearly 40 hospitals crossing California, Arizona, and Nevada. We are moving to the Cerner platform in the hospital.

Outside of the foundation, we also have some employed medical groups in Nevada and Arizona. The large one in Arizona is using Allscripts Enterprise. Then in Nevada and a lot of our clinics that are not part of the foundation … many hospitals have community-based clinics. There’s a hodgepodge of systems that are being used there. We are in the process of looking to maybe consolidate or figure out if there’s an enterprise solution that we can roll out to all of those sites.

 

Are you having any challenges to tie in Allscripts ambulatory with Cerner inpatient?

In some of our markets, we’ve done a better job than in others with creating the integration. I would guess that a lot of health systems have this challenge of integrating data and having it be seamless. Integration tends to be very costly. There are issues around patient matching. 

We have one of the largest private HIEs in the country. We use MobileMD, which was acquired by Siemens a few years back. We have nearly 7,000 of our physicians that have an account with that HIE. Primarily we’ve used that as a way for doctors out in the community to get information from Cerner, the hospital. Both the Cerner and the Meditech hospitals will feed data into MobileMD and then those physicians and offices in the community can access that. 

Leveraging that integration platform, we’ve been able to, for our own providers that are on Allscripts, create a pretty good integration. A lot of our Allscripts providers in Sacramento will get automatically delivered to their Allscripts platform discharge summaries and radiology reports and labs and things that are done in the hospital.

 

Are most of the physicians attesting for Meaningful Use?

Yes. Of the providers who are on a system that is up to speed with Meaningful Use, we’ve had a nearly a 100 percent rate of Meaningful Use attestation. The clinics where we don’t run them from a foundation standpoint, then those doctors tend to work in clinics where he hospital staffs it, but the doctors are independent contractors. There’s a lot more variability there because a lot of those doctors may be specialists who have their own practice and just come in a few days a month. We believe a lot of them are attesting in their own practices.

 

Are you looking at any specific Meaningful Use Stage 2 challenges?

Yes. For Stage 2, the biggest challenge for us is the patient portal. We’ve been working with a company called Medseek to customize a portal for our Allscripts users. We’ve made a lot of progress, but there’s still challenges in getting patient enrollment, in getting doctors to feel comfortable sharing the amount of information that needs to be shared to achieve Meaningful Use. We’re still working through a lot of those issues, but we feel like we’re on a trajectory to make that happen by the end of the year.

 

Did you make that decision before Allscripts acquired Jardogs and FollowMyHealth? I’m just curious why you wouldn’t have chosen it.

We did. Without getting into the specifics, there was a very detailed RFP that went out and Jardogs was part of that. There were, I think, some specific limitations that Jardogs had, not necessarily related to function, but more around privacy and security and the way that Dignity Health approaches those things that I think made it incompatible with our setup. That was all pre-date of the acquisition by Allscripts.

 

Describe the pilot that you’re doing with Google Glass and Augmedix.

I practice in a clinic in Camarillo. We have several other primary care doctors there. We learned of the Augmedix solution. As you heard me describe some of the other technologies that we’re using at Dignity Health, you probably didn’t hear a lot of excitement in my voice. [laughs] I try not to reveal my true feelings.

Technology for physicians, while we understand and we know that it’s where we need to go, it hasn’t always been easy to adopt. If you talk to most physicians, they probably wouldn’t say that the EMR has made them more efficient. Again, I think we all understand that it’s important and having access to that data will eventually be more important.

The Google Glass technology was something that intrigued me. How is this going to impact healthcare? Where will this fall? You can imagine lots of potential use cases for it, but what we liked about the way Augmedix was deploying it, it seemed to be something that added value to physicians that would improve their ability to interact with patients, to do their job more effectively and not feel like they were getting bogged down with technology.

The way that it works is we wear the device as we’re seeing patients. The audio and video are being streamed to the Augmedix team. Through a combination of humans and technology that’s proprietary to them, the progress notes are being completed. As a practicing physician, the ability to feel like you’re getting back to that doctor-patient interaction has been a tremendous experience.

 

I assume they use some type of back-end speech recognition with human review and correction and that information is placed in the EMR?

I would encourage you to reach out to the Augmedix people and have them explain it to you. I want to protect their proprietary endeavors there. But I would guess that there’s probably some combination of human and technology going on there.

My experience would tell me that it has to be different than just voice recognition. You would understand this better than people that have interviewed me that when you use Dragon or even traditional dictation, you as a physician have to summarize the encounter for that voice-to-text to happen. In this case, Augmedix has partnered with us. They came and observed our workflow, observed the physicians that are using it beforehand, they met with us, they understood how we like to document, how we like to capture our physical exam and other things. They’re summarizing in real time for us. The true medical elements of that conversation are making it into the chart.

 

That’s not customized for each physician, right? It’s somewhat of a templated formula of how you speak to Glass to get it to understand what you’re doing at that point?

It’s not fully customized. I don’t want to imply that you can have it any way you want, but there is some customization. They do take time to learn how we like our notes to look. Also things like as I’m examining the patient, they can’t hear what I’m hearing, so I have to be able to communicate that to them in some way. Things like, if someone’s exam is normal, then in the absence of me verbalizing what I found, they may use a normal exam template that we agreed upon.

Then other times, if I miss something, one of the great and nice things about Google Glass is they can send me a little message that shows up on the Glass device and says, hey, you forgot to tell me what you saw in their ear exam. So there’s some two-way interaction that goes on.

 

Did Augmedix have to interface into Allscripts or did Allscripts have to participate in the setup to get your progress notes into their EMR?

Our version of Allscripts is hosted internally by Dignity Health. The Dignity Health IT team worked closely with Augmedix to sort that out. We ran everything through the privacy and security and compliance people so that the way it’s set up, everyone’s very comfortable with.

 

The release used the word “partnered.” There’s no financial interest either by you personally or Dignity Health with Augmedix, right?

Correct.

 

This is a three-physician pilot. What are the plans to roll it out further?

We’re currently looking in negotiations with Augmedix to expand to other physicians in Ventura. We’re excited about that opportunity. Then depending on how that goes, we may look to roll it other sites within Dignity.

 

What’s the patient reaction to using Glass in their encounters?

Overwhelmingly it’s been very positive. That’s definitely a question I had going into this — whether or not patients would accept it. I don’t wear glasses normally, so I was kind of curious what my patients would think of me wearing something like this. 

One of the most surprising things is how many of my patients don’t even seem to notice. I think that probably has to do with patients coming in not feeling well or looking for help and focused on their concerns. When they come in now and see that I’m not typing, that I’m just sitting there, looking at them, waiting and listening and asking pointed questions about what’s happening — they almost don’t even notice that I have it on there.

There’s another group, obviously, that’s more tech savvy. They recognize that it’s a Google Glass and they’re interested in that because they haven’t seen one yet and they want to know what is it like. But even that, too, is a really short conversation. I explain to them what’s happening, that the information is being transmitted, and that this is helping us to document so that we can spend more time with them. 

Across the board it’s been very well received. They even get a little excited about the fact that their doctor is using a new technology. It gives them confidence that we’re looking to whatever it takes to provide better care for them.

 

Are there still things in an encounter that you have to use a keyboard or a tablet for, or are there things that you would like to see added to what Augmedix can do to make it complete so that you don’t have to use any other device?

In this first phase, we still have to do our orders. We didn’t feel comfortable yet turning over the keys to that CPOE engine given that there’s a lot more important things going on there, like we should get the right medicine ordered, right labs ordered, those kinds of things. 

Usually that happens at the end of a nice interaction with the patient, though, where we say, “OK, this is what I’m going to do for you.” That’s when I can turn and enter in some orders. But I think that’s a much more accepted thing for patients because they feel like they’ve had their time and now you’re actually doing something for them. When you do have to turn to your computer to do that, I think that’s an appropriate thing.

We are looking and hoping that as the technology matures, both the EMR and the Augmedix technology, that maybe at some what point we can verbalize those orders and that our voice can be recognized and authenticated. Who knows what that will turn out to be? But I am optimistic that we can push the limits of that.

 

Is it storing video or audio or both from the encounter?

At this point, no. I think our compliance people and everybody wasn’t comfortable with that yet, is my understanding. It’s an interesting thought, though. I think I saw an article recently where someone else was looking to maybe record video and audio right into a medical record, which I thought was an interesting concept. But we’re not doing that.

 

People always say technologies don’t preserve the patient’s story or the full richness of the encounter, so it would be pretty cool to say, “I want to see this whole visit over. I want to hear what I said, what the patient said.” That would be interesting documentation, although certainly there’s privacy and litigation concerns on both sides.

Absolutely. Once people feel comfortable that there’s technology out there that would really keep that safe, then I think we’ll move in that direction.

 

Dignity recently formed an accountable care organization. What lessons are you learning about the need for data and analytics tools?

ACO is kind of a broad term. There are several ACO-type contracts throughout Dignity Health in both California and Arizona. Some of them are more along the shared savings route and others are maybe more along just some metrics and other things. Clearly we understand the need for having access to data across the continuum of care. We need to be able to see longitudinal view of a given patient in order for us to really understand what it’s going to take to care for that patient and partner with them in helping them achieve their health goals.

 

What other projects are taking the most of your time and energy?

I’m working on projects with population health. We are looking to create what we call our population health management technology stack. You described the need for data — we’re looking at getting the data gathered for the first phase, then getting into the analytics layer, care management, what we do with that data, the clinical and patient portal-type interactions. 

Related to pop health, we’re looking at collaboration tools, secure messaging tools, video visits … the list goes on and on. I think there’s probably a common list that you would hear from any big health system that is trying to anticipate what might be needed as we turn the corner on healthcare reform.

 

You’ll be buying and implementing quite a lot of systems over the next several years.

Yes. We are in the process of looking for vendors who, in some cases, have the maturity for us to buy them and purchase. But in most cases, especially in the population health space, we’re looking to either build or partner to co-develop solutions. I think it would be naive of us to invest too much money in a "solution" when nobody really knows what’s exactly going to be needed. We’re going to be very busy for a few years on that front.

 

Do you have any final thoughts?

I just want to say that I’m excited to be a part of Dignity Health. I’ve only been here for a couple of years. I came on at a really good time. I arrived right about the time that they were changing their name from Catholic Healthcare West to Dignity Health. I’ve seen a trajectory in this company that seems to really understand where things are headed, but not losing sight of the mission and value, this campaign around human kindness. 

This particular Google Glass pilot and project has demonstrated that Dignity Health is willing to put their support and invest in projects that go in line with that. I’ve done a lot of technology stuff over the years, but this is one of the first that seems to excite every physician that comes around it, which is different from a lot of technology. I think the reason is because it really does get us back to why we got into medicine, which is that patient interaction, making a difference and feeling like you’re using something that’s more transparent and that is helping you as opposed to getting in your way.

HIStalk Interviews Farzad Mostashari, CEO, Aledade

June 20, 2014 Interviews 9 Comments

Farzad Mostashari, MD, MSc is CEO of Aledade of Bethesda, MD.

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How do you pronounce the company’s name? Is it Allay-DODD?

Allay-DADE.

Explain the company’s business model and what Venrock’s interest is in backing it with a significant investment.

The business model is pretty simple, actually. We’re going to give physicians – independent primary care practices – pretty much everything they need in order to form and join an ACO. The key business model for an ACO in this case is that the main revenue source for us comes if and when we generate total healthcare spending reduction and improvement in total healthcare quality and coordination.

This is all predicated on our belief that with the right tools, with the right technology, with the right boots on the ground, with the right team, with the right primary care providers, we can go right at the heart of what’s ailing healthcare today and get to better care, better health, and lower cost. If we can do that, the company prospers and the primary care docs prosper.

 

Who actually writes you checks and how do you calculate that savings that I assume you’re getting a percentage of?

There is an organization, an accountable care organization, which we will stand up. That entity then enters into contracts with health plans. The contracts with the health plans basically say, “You have a projected total cost for this panel of 5,000 or 10,000 patients. If we come in below that benchmark, the health plan gets half and the ACO gets half.” The largest plan in the world, Medicare, now has this available for primary care providers throughout the country. Many other health plans are following suit.

 

If I’m a physician and I decide I want to get in on this ACO thing, who are my fellow members or should I even know or care?

Healthcare is very local. We believe that you need boots on the ground, like the Regional Extension Centers in a way, harking back to that. Or even before that, to my experience with Mat Kendall, my co-founder, when we were in New York City. We went to 233 independent practices and we enrolled them in the Primary Care Information Project. This is similar, where in a given geography, we get a field team out, we find the right practices, and we bring them together, oftentimes with practices in a group they haven’t worked with before.

But really the work is done one-on-one with the practice. There’s a common set of tools — referral management tools, patient management tools, and risk management tools — but the real work happens in an individual, given practice, with the team going into the field.

What we’re looking for isn’t really networks of docs that have already come together. We’re looking for the independent, individual practices who might have thought, gee, I really want to get into this, but I’m just one practice — I only have a few hundred patients. They can’t by themselves enter into these risk arrangements. They need to be part of a bigger group. We’d be aggregating them with other docs who could form the core of this new high-value network.

That’s part of the value proposition we offer. It’s not that we’ll sell to anyone or work with anyone. A big part of this is the filtering out to make sure the people — the people you’re in the boat with — are really the people you want to be in the boat with.

 

What’s the risk to the practice?

Risk is something we have to manage. One risk is that it turns out there’s someone in the boat who’s not pulling their weight. Part of what we have and part of what Medicare requires is some incentives within the ACO that say, “We’re not just going to divide up the shared savings totally equally.” How much your participate in the ACO makes a difference in how much of a share you get. How do you on the key performance indicators determines how much of a share you get. In extreme cases, if someone’s really not doing anything, you can be expelled from the ACO. You can be voted off the island. That’s one risk.

I spent nine months at Brookings becoming a little bit of a student of ACOs that have succeeded and those that haven’t. One of the risks is if you don’t understand the regulations and their implications. This is one where being someone who’s been a regulator before and who understands how the regulators think is pretty helpful — to be able to reduce that risk for them. To say that I understand and our team has an in-depth understanding of what the regulations say and also what the implications of them are so you avoid some of the gotchas that have gotten people before.

 

I assume the doctor’s entire panel doesn’t just go ACO — there’s some blend of insurance patients and then adding new patients and converting some patients.

Exactly. This is perfect because it helps you transition.

It’s really hard to be going from one day doing fee-for-service regular practice and the other day to be taking full cap risk as part of Medicare Advantage. That’s not really feasible. There’s no health plan in the world that’s going to just turn over full risk contracts to you if you haven’t had the experience with this.

This is an ideal transition path for practices who know that’s the direction they’re in, that the future is value-based purchasing and being able to take accountability for total risk. This is training wheels, one-sided risk from CMS for three years. I’d love to go to a casino that gives me one-sided risk. [laughs].

In this model, if you get savings over the threshold, you share it with CMS. If costs go up, you don’t have to pay CMS the difference. It’s a really perfect opportunity for them to begin to gain the skills, gain the competencies, gain the tools, and then ramp up the risk. Ramp up with the number of different health plans that are participating. Expand to other commercial plans — as I said, more and more are going to be willing to give you these sorts of deals if you’ve proven your ability to manage risk. Then ramp up in terms of the kinds of risk you accept.

Initially, maybe you start off with one-sided risk. Then in three years, if you’ve done a good job with that, then you can feel more confident to move to two-sided risk or even delegated capitation agreements, where you get paid upfront for managing the total cost.

 

You mentioned the boots on the ground approach. Is this tied in any way to the Regional Extension Centers?

Well, you know, I have been a huge fan of the work of the Extension Centers. I’ve been saying for some time that the future for those Extension Centers is going to be in providing not health IT help, but actually getting into practice transformation. There’s not the funding available from the federal government for them to expand in a major way and to have a sustainability for those Extension Centers.

But you know, this could be a set of services that they could contract with us or anyone else to provide. This could be part of the sustainability model for Extension Centers moving forward if those Extension Centers have demonstrated their value to the providers and have the ability to move beyond just health IT to true practice transformation.

 

Assuming you work with the RECs in some capacity, who do you employ within the company?

There’s a set of central resources that you need that you don’t want to duplicate for every ACO — for every ACO to have their own legal team and have their own regulatory review and have their own IT team. 

One of the things I’ve realized is once you are doing this ACO work, I can’t tell you the number of IT companies who assure me that they have the solution for me. [laughs] I’m the former National Coordinator for Health IT. I’ve seen a few products in my day. I have a sense and my chief technology officer Edwin Miller has been involved with some 30 different products. We have the ability to weed through and find out what makes sense to buy, what makes sense to build, and how do you assemble this all into one integrated technology platform. For a small ACO to do that, that’s just prohibitive.

I’ve talked to many ACOs  who a year into it say, “We haven’t done anything because we’d have to start all over with our IT vendor.” That’s part of the central support that they get — the integrated technology platform, the data, the analytics, the regulatory, the legal, protocols, all that stuff. Then that’s partnered with the boots on the ground, which are local to them. A medical director who’s dedicated to them. A nurse coordinator. The project managers and transformation staff who go into the practice. The best of both worlds.

 

You mentioned EHR optimization and the integrated data and technology platform. Do you anticipate working with the EHRs each practice runs or will you have a relationship with vendors that will become the standard for the ACO?

Step one is I’m going to pre-select the practices based on their ability to demonstrate Meaningful Use. For me, Meaningful Use is, “You’ve got to be this tall to ride.” Because without that, you don’t have the data to be able to make all this work.

Two, you and I know well that the EHR systems are not optimized, particularly for population health. We’re not going to rip and replace people’s EHRs, but we’re going to optimize the hell out of them. Make sure that the efficiency is there, that the workflows make sense, that the work of documentation doesn’t all fall on the poor doc. That you actually make use of the data you’re collecting. That their decision supports are meaningful and tied to the quality measures they’re trying to accomplish. That the registry functions actually work as intended.

Our team will have something of an advantage having not just implemented the certification and Meaningful Use qualities, but having actually built, with Edwin, three cloud-based EHRs that met the Meaningful Use requirements. So step one, make sure that they have the basic foundation.

Step two, optimize the heck out of them. Step three, bring to bear the tools that EHRs aren’t really built for. I wrote about this after HIMSS last year. There are too many people selling shrink-wrapped population health — reporting, really, not management — tools that are trying to automate stuff when we’re in the discovery stage. I think the first infrastructure we really need is a discovery set of tools, where you have a very flexible data architecture underneath with some very flexible data analytics tools on top. Then you figure out what it is after you do discovery. Then you create protocols. Then you move to automation.

We’ll look at what’s available right now in terms of both the fundamental underlying data architecture, the middleware tools that are needed, the analytic tools that ride on top, and then some frameworks for being able to create custom visualization into that framework. As I’m describing it, I’m sure you are seeing the flavor of what we’re building is not monolithic software platforms or enterprise pieces of software. It’s really more of a platform that becomes a chassis with separation between the logical layers.

 

There are a lot of certified products, so in a given group of practitioners that might want to be part of an ACO, you might have 10 or 15 EHR systems. How can you optimize those systems not knowing them first-hand like the users of those systems do?

I think we’re going to need to probably develop and hire and add to the team people who are experienced and experts in each of probably the top half a dozen, maybe eight EHRs, that will probably account for the bulk of our practices we want to work with. That’s one. 

Two is to work with the vendors. This is one of the advantages that I’ll have. I’ll continue to take a vendor-neutral approach on the EHR side, which is more comfortable to me, and I’m sure there will be some that see the opportunity to work with us and will be able to learn from us even as we are working with them to optimize their solutions for the practices.

The EHR vendors need to learn how to optimize their own systems for population health management. There will be no one better to work with than us in terms of figuring out what that means.

 

You’ll be supporting some number of the more popular EHRs and then building the data layer that’s aggregated across all members of the ACO and you’ll provide analytics and population health management tools to sit on top of that?

Correct.

 

From the physician’s standpoint, you’re handling the administrative overhead. They’re just using the EHR they’ve always used and it’s somewhat invisible to them other than optimization changes or changes to meet quality standards. You’ll report back to them from the centralized version of their data collected with everyone else’s.

That’s right. Same EHR, just better. [laughs]

 

Hospitals and even practices are hearing “ACO” and are writing checks having no idea what they need or want. Will people get burned trying to jump too early on what they think the future will be?

I think this is a key risk for for ACOs — jumping on with the wrong technology and the wrong technology platform. Assuming that there’s going to be some magical ACO technology that’s going to solve your problem. This is still very much about discovery before we get to automation.

 

What have we learned about ACOs since the arguably mixed success of the Pioneer group? Can ACOs work everywhere and not just in areas where Medicare is paying too much?

Great question. I think my team at Brookings was the first to actually identify the individual 29 who had gotten shared savings and then start to look at the predictors and correlates of that.

What we found was that, one, it had been assumed that the Pioneer-type ACOs, the big integrated delivery networks, were going to blow the small physician-led ACOs out of the water. That was not true. Thirty percent of the physician-led ACOs demonstrated savings in Year One versus 20 percent of the hospital-sponsored ones. That’s a really interesting observation.

The second observation that I’ve had in a more qualitative than quantitative way has been that among a lot of ACOs that didn’t succeed, there were three factors and one underlying issue. The one factor was that they didn’t understand the regulations. The second factor was that they didn’t use data. They didn’t use data, they sat on the data, this treasure in the form of the claims data of every client paid by CMS, they just sat on it. They didn’t do enough with it. The third thing was that they didn’t change practice enough. They had monthly meetings and that was kind of it. If you do that, it’s too hard. You’re not going to generate savings.

I think those three factors are going to be more important than where you are. It’s can you use data? Have you invested enough, both in terms of your time and in money, in changing what you do? Third, do you understand the regulations? That’s what I’m bringing to the practices.

What you still need — and no one can hand it to you — is will. The will to change. That’s what we have to select for.

 

Hospitals I’ve worked in were swimming in data but didn’t act on it because there wasn’t enough imperative. Do we have enough data to move to a value-based payment model? Do you think the economic pressure will be enough to get people to pay attention?

I do. I do. Particularly for the smaller primary care practices.

With the hospitals, it’s more complicated. A, they have tons of competing demands. Forget about academic medical centers who have the teaching mission and the research mission and all of that mixed in. Even in just the tertiary care setting you have all these entrenched structures that reflect the fee-for-service optimization world.

For the hospital, life begins with the emergency room admission. Now you’re asking them to think about how to prevent an admission. That is totally foreign to a hospital and totally schizophrenic in terms of their revenue, where on the one hand they’re trying to reduce admissions, but on the other hand that’s their revenue and their bread and butter — heads in beds.

With a physician — and particularly a primary care-led ACO — it’s much easier. One, you don’t have tons of committees [laughs] to navigate through. It’s a small practice. The doc gets together with the office manager and their nurse and they say we’ll do this, and they do it, and it happens. I’ve seen time and time again in trying to make changes that it’s easier in the smaller practices than in the larger institutions.

Two, the incentives are much more meaningful to the primary care doc who is making $150,000 a year. That’s their take-home pay — $150,000 a year on average. For them, saying you could make an extra $50,000 or $100,000 – that’s really meaningful. That’s game-changing for them, whereas for a hospital to get back half of the revenue that they lost, that’s not really a game-changer.

 

How do you see small practices being configured differently with primary care docs getting squeezed by mid-levels and then operating under an ACO model?

We’re not going to try to totally upend the practice. We’re going to start with pretty simple stuff. Is there going to be someone to answer the phone at 9:00 at night when the patient calls or is there an answering service that says to go to the emergency room? That’s not totally upending the practice structure, exactly.

I think in the ultimate manifestation of really optimizing for value, what I suspect we’re going to see is primary care providers using referrals as consults. Neil Calman at the ACO Summit talked about how when as a group of family medicine docs they took over a practice that had tons of specialists in it – 10 orthopods and a hematologist or whatever – and they looked at what the patients were coming in for, they realized this is family medicine stuff. They were managing people with stable anemias. They were managing people with stable seizure disorders.

Use specialists as consultants, not to manage patients with stable conditions. That’s an example of disruption, where the primary car doc starts to do more of the work and not just refer patients reflexively to this specialist for this and that specialist for that and a third specialist for that and a fourth specialist for that. 

Their job, frankly, is going to become a lot more interesting. That lets them shed some of the boring stuff that pays the bills today – the strep throat, the poison ivy. Let the mid-levels do that. Heck, let the urgent care center do that. Let CVS do that. Focus on what the highest value work is that each part of the healthcare system can provide.

 

Where do you hope the company is in two or three years?

For me, I want to have the most successful ACO in the country. [laughs] That to me is success, where we’re the best. We’re the best. We figure out how to use data and technology to bring the focus on the outcomes.

Gosh, I just can’t wait to tear into the meat of what we’ve needed to do, which is about the outcomes. It’s about being able to focus on how do we get measurably better health, measurably better patient experience, and lower cost. And use data and technology in really fundamental ways to accomplish that, but to have our eyes on the prize instead of structures and processes and so forth.

 

Do you have any final thoughts?

It’s an exciting time. This is in some ways a strange turn for me to do a startup and join the ranks on the private sector side. But in other ways, it just feels incredibly familiar to me. [laughs]

Let’s start with a blank piece of paper. Let’s think about what the world needs and build a team, build an awesome team, that can use data to improve population health. In a way, I feel like I’ve been in training for this all my life.

HIStalk Interviews Aaron Sorensen, Director of Informatics, Temple University School of Medicine

June 16, 2014 Interviews No Comments

Aaron Sorensen is director of informatics at Temple University School of Medicine of Philadelphia, PA.

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Tell me about your job.

I’m at Temple University at the School of Medicine with an affiliated health system. Our new leadership is keen on creating a robust infrastructure to support clinical research. I’m heading up the informatics aspects of that.

 

What is the informatics influence in the School of Medicine?

Within the health system, you have the IT shop that runs a myriad of clinical systems. There’s a feeling from the researchers that all this data exists, but it’s hard to get at. What do you do with it once you have it? What are the appropriate safeguards regarding compliance and privacy? 

The School of Medicine is trying to make it so that every time a clinical researcher wants to ask a question of the clinical data, it doesn’t become a maze that you get lost in, with different people are telling you different things. There’s this straightforward way to do it and you can go to a central team of people that will guide you through the path and help you along your way.

 

Describe how PCORnet came about and what it does.

My understanding is that over 10 years ago, when the NIH was originally thinking about redoing the way they fund clinical research extramurally at academic medical centers, the PCORnet idea was floated. The feeling was that it would be costly and it would be hard to achieve. They had other priorities, so instead of doing that, they funded the CTSA awards.

PCORI, the Patient-Centered Outcomes Research Institute, is not a federal organization, but it’s funded through the Affordable Care Act. It’s federal dollars, but it itself is a independent non-profit. The feeling was that it was worth pursuing the idea of creating a network of hospitals that have the ability to share de-identified patient data for the purposes of clinical research. 

Although they have grants that fund all different kind of things, just like the NIH does, I believe the crown jewel within the PCORI portfolio is PCORnet. It has 29 funded groups, some of which focus more on general health system patient populations, whereas others are more focused on particular patient groups with specific diseases.

 

What Temple systems are contributing data to PCORnet?

In terms of our electronic medical record, we’ve been on Epic outpatient for about three years. We’re just now kicking off the project to go with Epic inpatient. Epic, as most EMRs, receives a number of feeds from different systems. When you get to the back-end Epic reporting database, you not only have the data that originated in Epic, but from a number of different systems.

For our contribution to PCORnet, we are only using our Epic back-end database that gets feeds from cardiology systems, pulmonary medicine systems, and billing type of data. It’s a wide range of things. For the purposes of this project, we are only using what comes into our central EMR.

 

Can researchers query data from any or all of those 29 contributing organizations?

Yes and no. The 29 break out into two groups.

The patient-focused ones that are disease specific are called PPRNs, the Patient-Powered Research Networks. The health system ones, of which Temple plays a role, are called CDRNs, or Clinical Data Research Networks. 

I don’t know 100 percent what the PPRN plan is. I think it’s slightly less ambitious than the CDRN plan of which I’m a part. I can speak to the 11 funded groups that are part of the CDRN and that cross the country. 

There are two aspects to the PCORI contract. Our network is the University of Pittsburgh, Johns Hopkins University, Temple, and Penn State Hersey. Within our network, we have been funded to create the ability to share data for two different diseases. One is rare disease – idiopathic pulmonary fibrosis. Then a more common disease, for which we chose atrial fibrillation.

At the CDRN level, at the national PCORnet level, we have to support two cohorts. One is what they originally called an obesity cohort, but then they decided they wanted to expand beyond people who are already obese to include people who are at risk of becoming obese. They’re now calling it the weight cohort. We’re going to support a weight cohort. 

Then we have to have a randomly chosen one million plus patient pool from which PCORnet can do centralized queries. Each of the 11 groups has to make available at least one million randomly selected patients, or else their whole patient population, for these centralized queries. As well as a subset of that which will be used specifically for to measure issues around obesity. For that group, you have to have collected good data on weight, height, calculating BMIs, and things around diabetes, coronary artery disease, and certain co-morbidities associated with obesity.

 

Do researchers have to file paperwork for what they’re looking for? Can you tell how they are using the system?

Yes. Within our network, we have IRB protocols that have been set up to allow for the researchers to ask certain questions. That’s specified ahead of time and is pretty locked down.

For PCORnet, they have the ability to ask anything. The data is always de-identified. You’re not typically ever sharing patient-level information. You’re aggregating it so that they can get an understanding within a given population how it breaks out — what the demographics are, what the prevalence or incidence of a given disease is, etc. 

For those questions, they are not pre-established. It’s not like at the beginning of the project that we know, “We will ask these 100 questions over the next year and a half.” Each funded site will have the ability to not respond to a given query, assuming that they have good justification not to do so.

 

The advantage to the researcher is that they might need to reach outside of Temple to identify a patient cohort large enough for their project, right?

Exactly. For our rare disease, idiopathic pulmonary fibrosis, at the time we submitted the grant, we estimated that we only had about 70 living patients with that disease. If you went to Pitt, which was the highest, they maybe had about 350 or so. 

With only 70 patients, maybe you don’t even have the number to show any statistical significance in certain differences between drugs or other interventions you’re trying to assess. Whereas if you were to combine all the centers together and you get above 500 patients, then all of a sudden potentially you have the ability to make a finding that will stick with the general population.

 

Is there a plan to add organizations or conditions or to use the data more widely?

Yes. We were initially funded for 18 months. That 18 months is supposed to be used largely to build an infrastructure to support future research. There will be some research done during the 18 months, but the idea is to make sure you can set up this robust network for the future. 

PCORI has said that they will be having a Phase 2 in which no longer will they be paying to help you set up this infrastructure, but instead they will want specific questions answered. You have the ability to then apply for Round 2 funding, in which you will potentially participate in clinical trials where, using the network, you identify certain patient profiles and you go out and enroll them in certain studies, or for large-scale retrospective studies, where you harness the power of the longitudinal data you have for your one million plus cohort of randomly selected patients times 11.

So at least 11 million patients that you can then query to say, over the last 10 years, patients with this profile who were given this type of therapy, how did they fare over the last 10 years compared to this other therapy? There will be a Phase 2 where we can extend the funding to actually try to answer certain questions.

In terms of being awarded the contract, everyone was being asked, to what level is your institutional leadership committing to making this sustainable over the long run? Should the money dry up tomorrow, do you have strategies and do you have commitments from your top leaders to make sure that this stays in place and that you extend it to anyone outside of the network so that any non-funded investigators have the ability to ask any center and consortium … my consortium is called PATH , the initials of all the participating institutes. Geographically, we’re the mid-Atlantic CDRN. So anyone in our geographic area who is not at a funded institution has the ability to request access to our data and to collaborate with any of our investigators on any particular study.

 

Is there anything else you’d like to talk about?

The one really neat thing that’s come out of this that’s linked to PCORnet is the use of i2b2. It stands for Informatics for Integrating Biology in the Bedside. It’s an open source software package created at Boston Children’s. It is used extensively throughout the Harvard-Partners HealthCare network. It allows you in an open, non-proprietary way to take data out of any clinical system, merge it with other data you might have – such as genetic data from other systems — and to make it queryable, both at your institution or potentially teaming up with other institutions. The adoption rate has been growing by leaps and bounds.

Temple was not an i2b2 user before this initiative. While we are implementing it for the purposes of PCORnet, as are many of the other CDRNs, we also are using it as a springboard to create an internal tool that our investigators can use for any patients of any disease asking potentially any questions using the EMR data. 

A lot of times when an institution implements a new clinical data warehouse, they take their time and go step by step. It evolves over a period of years, potentially. Whereas because of this PCORI initiative, we had to go from zero to 60 quickly. Phase 1 lasts 18 months, and at the end of 18 months, you have to show that you’ve successfully created this infrastructure which can be used for robust clinical research. 

The i2b2 prevalence within academic medical centers over the US has been growing. As I dug into it, I realized that people use it in different ways. If you are trying to share data with another institution via i2b2, one approach is to try to convert all your data to the same standard. If you have internal lab codes and the other institution has their own internal lab codes, you could try to convert all your codes to a standard like LOINC. Or, you could allow them to stay as they are and then you have some lookup table that converts on the fly from your local ones to a standard.

As I was experiencing this and going through the baptism by fire of getting our institution using i2b2, not only for PCORI but for ourselves, it became clear that there should be a boot camp that helps you think about all these things. It needs to give you what I call the mental scaffolding, so that from the beginning of a project, you can consider all of the types of decisions you’ll have to make and the potential downstream ripple effects.

I contacted Harvard, the folks that created i2b2 and the accompanying SHRINE software that allows you to connect other institutions. I gave them some ideas about how it would have been great if I had been able to take this intensive boot camp before our project started. We went back and forth and we’re going to offer a pilot i2b2-SHRINE boot camp at Harvard in early 2015. 

Harvard is trying to assess what type of a demand would there be for such a boot camp after the pilot. We’ll try to fill maybe 25 spots with the pilot, but then whether there is enough hunger and demand to offer it regularly. If any of your readers have any thoughts about that, I’d love feedback in order to gauge whether it’s a minor niche thing or if it has wide applicability.

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