HIStalk Interviews Paul Brient, CEO, PatientKeeper

Paul Brient is president and CEO of PatientKeeper of Waltham, MA.

Tell me about yourself and the company.

I’ve been in the healthcare IT business for my entire career, which is now about 25 years. PatientKeeper has been around for about 14 years. I joined 11 years ago. Our focus has always been to create technology that would help automate the day and the life of a physician, in a way that the physicians would see as a benefit to their workflow. We’ve been fighting the good fight for the past 14 years.

When you and I talked in 2010, CPOE adoption rates were tiny, especially in community-based hospitals. Is that still the case?

Certainly if you go about it in the traditional way, it’s still the case. There’s not a lot that’s changed in terms of the approach of classic CPOE vendors. There are many hospitals out there that are really struggling to get to 60 percent CPOE adoption. You hear stories of them having to badger and cajole and threaten physicians to make them use CPOE.

The essence and the core of the problem is that legacy CPOE applications reduce physician productivity. They spend more time taking care of the same number of patients than they did before. If you’re in private practice as a physician, that’s pretty devastating. For the healthcare system overall, automating the most expensive asset, or the expensive worker in the healthcare system, and making them less productive is not a win. 

In our view, we need to have a different approach to physician-facing technology. We have approaches that make physicians more productive, more efficient, save them time, and ultimately help them practice better medicine in a way that is consistent with the way they think they should be practicing medicine.

Hospitals were making their captive doctors use CPOE 100 percent while assuming that usage by the community-based docs would be nearly zero. Are hospitals paying more attention to the productivity and the satisfaction of their doctors?

I think they are, but they’re really torn. Many hospitals are torn between going after Meaningful Use and that’s what they’ve been told to do and it’s the right thing to do, and make the physicians happy. In many situations, those are somewhat exclusive.

One CIO showed me a graphic, saying, “As we’ve increased technology available to our physicians, we’ve decreased physician satisfaction pretty much in these relationships.” I think that puts a lot of CIOs between the proverbial rock and hard place. But I think most organizations right now are very focused on Meaningful Use and are having to sacrifice physician satisfaction in the short term. That’s probably not a long-term, sustainable strategy.

Everybody talks about the reduced productivity with CPOE. Do you think it’s mostly due to the poor application design for physician usability or the requirements by government or others that doesn’t benefit patients all that much?

As it pertains to CPOE and even documentation, there’s not a lot of government regulation that makes it difficult to use. It may make it difficult to write the software and get it out there and everything, but not difficult for the physicians to use per se.

I think the historical problem is that CPOE to date, from the classic way of getting it, is through an HIS vendor. Those systems evolved out of the back-end infrastructure. The physician has to learn how to put in orders in the way that the back-end system wants to consume them. That is not the way physicians are trained. Doctors have to go to two, three, four, five days’ of training just to be able to use these systems because they’re having to re-conform the way they think about ordering and the way they do stuff to the way the back-end systems in the hospitals process orders. That’s a way of doing things; it’s not a way to create great productivity.

An alternative way, which is the way we have approached the system, is to start with the way doctors think about ordering and build a computer system that translates it and gets it into the form that allows that order to be processed. If you think about the difference between like a Windows PC and an iPad in terms of user manuals and configurability and all this stuff, you pick up the iPad and it’s intuitive to use it. When we put a CPOE system in front of a physician, they mostly can just use it. Maybe it takes them 5, 10, maybe 15 minutes of training to be fully proficient. 

It’s not usability in the classic computer science sense. It’s about having a system that is designed from the beginning to work the way that doctors work. Then you get to do a whole lot of work in the back end to make it work the way the hospital does, because if they can put the order in but it doesn’t go anywhere, that doesn’t do anyone any good. It’s not an easy task. It’s a very different approach than anyone else has taken to date. I hope that as we move forward in this industry people take a different approach and focus more on the physician workflow and try to get systems that do mirror the way physicians have been trained and the way they practice.

Who would make that change? It’s almost all Cerner and Epic in hospitals at this point, and I assume that in your mind, both have usability problems.

You mentioned Epic. It takes two days to learn how to use. Obviously there’s a ways to go in terms of easy use and usability just from that fact alone. 

In terms of the “who,” this depends a little bit on whether we’re committed to an open, interoperable world. The government or anyone else didn’t make the edict that every single piece of IT used in a hospital should come from one of two vendors and you only get to pick one of them. That’s a pretty closed view of the world. There are other views of the world that would allow people to create best-of-breed solutions, whether it’s for specialty, or for different kinds of people within a hospital, whether it’s a physician or a nurse or phlebotomist, or whatever. And be able to have those systems automate those people in a fabulous manner and have the data flow back into those core systems. 

Frankly, the Cerners and Epics and even the Meditechs of the world, they run your hospital really well. You don’t hear problems of the laboratory folks or the pharmacists complaining about their Epic system or their Meditech system or their Cerner system. They actually do a really good job. They’re much more mature, especially with Epic. Cerner started out as a lab organization, a lab automation company. These systems are very mature and work really well for these folks. The challenge has been the doctor and some of the other caregivers that we don’t address. Certainly nurses have a fair amount of frustration. Some of that really is because the regulations and the requirements that are being placed on them. 

I think the solution to this is to have innovation. If we just have to get all our software from two vendors, that’s not necessarily going to create the most innovative part of the world. If you look at what’s happened elsewhere, like Salesforce.com and their ecosystem they created for our vendors. We run that as our core CRM system, but we run applications from three or four other vendors because it does it better than Salesforce.com. Salesforce.com opens their APIs and helps you buy them and all kinds of stuff. Hopefully we’ll be able to get to a place where the HIT world is like that.

We as PatientKeeper are trying to find ways that we might be able to leverage our technology and our 14 years of R&D to make these systems open for others as well. I’m not quite sure exactly when and how we’re going to do that, but we’re very committed to seeing innovation happen.

The challenge is that hospitals wanted one neck to wring, as they say, and chose single-vendor solutions even if they had to give up some things. What would be the driving force for that innovation if the customers don’t seem to want it and the two remaining dominant vendors that are out there don’t seem to have much incentive to change?

Just what we were talking about with physicians, we’re going through this Meaningful Use march. You see a lot of organizations that are really struggling to get to full physician adoption. Having two workflows, even if you can check the boxes on Meaningful Use and get to your 30 and 60 percent for your lab and pharmacy orders, that’s not a way to run a hospital. You want to get to 90 something plus percent. If you’ve slowed down your physicians and your physicians are complaining, you’re going to be in a big world of hurt. 

Certainly while any new sales of hospitals are going to mainly Cerner and Epic, more than half the hospitals out there don’t run Cerner or Epic right now. I’m not sure that they’re going to all magically convert over in any short period of time. I think we still have a world where there a bunch of hospitals out there really struggling with what to do with stuff that’s even more challenging to use than those two vendors. So yes, it’s going to be very interesting to see of best-of-breed versus one system thing. It waxes and wanes. 

In the rest of the world of technology, the notion of a single, closed, proprietary system that doesn’t allow support an ecosystem or support inoperability is pretty much passé. Technology is so good to be able to exchange data and integrate data. I hope that healthcare will ultimately succeed. It’s hard to put a crystal ball and see exactly how, but I think there’s been a lot of forces and they’re at work here and hopefully they will converge to create both the technological ecosystems but also the market demand for better systems for doctors.

Meaningful Use threw that equation off where it pushed people to buy the same old systems today, and hospitals spent whatever money they’re going to have for a long time. Is that an environment that will allow or encourage change? Do you think the Meaningful Use has degraded the market from where it would have been otherwise?

It’s certainly had an impact on it. It’s hard to say. It’s almost like you want to have a parallel universe, one with Meaningful Use and one without, to see exactly what would have happened.

The good news on Meaningful Use is that it got everyone focused on doing CPOE. The challenging news for some, as you point out, is that when we went out to look, if you’re a hospital looking for what the options are, there are only a few options. It is what it is. 

As people are now getting to the more mature phases of Meaningful Use and starting to look beyond it, that that’s where the opportunities are going to get created. When you’re trying to, “ I have to get to Stage 2. I’m going to check these boxes,” a lot of people went out and did the short putt, or in many cases, just took what they had and said, can we make it work? What we’re seeing is a lot of organizations that did that — and might even be at 50 percent or 60 percent utilization — but they are now saying, look, this is too painful. This is not sustainable. We need to do something different. 

They’re looking for options. PatientKeeper’s one option. There are other options out there. There a lot of creative solutions out there that people are starting to try. I think that as that pain becomes more acute, that will create receptivity to more and more creative options other than taking the HIS system I have now and try to deploy it more and more.

The world has changed a lot since PatientKeeper was formed. I think it originally ran on a Palm, if I remember right. Do you think that the way clinicians are using and expecting to use mobile devices has changed more than even on the consumer side?

Your memory’s good. It’s really interesting if you look at the mobile device world and you take a snapshot in time. Even when the Palm first came out, people said, well, gee, finally. If you recall what happened before the Palm, there were about 50 startup companies that tried to build a pen-based PC and failed. It was like for a while, Palm was it. Then you could take a snapshot in time and say, BlackBerry was absolutely it — that was a solution for all things mobile. 

There’s a point in time, and I think that point in time is actually starting to pass, where the iPhone looked like it was the only solution and the end-all, be-all. That’s starting to change, too. The Android devices are arguably much more innovative and more creative. The Android tablets are pretty darned compelling and half the price of an iPad. Who knows? It’s very hard to forecast what’s going to happen.

I’m certain, though, that mobility will continue to play a very big role in everyone’s lives, including physicians’ lives. I think physicians in general are probably a little behind the curve, in part because many HIS systems don’t have good mobile options. They can’t do core workflows in using mobile devices. But that’s changing. Companies like PatientKeeper and others are coming out with all kinds of cool, great devices to help physicians, and there are a million apps out there for them. Mobility is going to continue to be really, really important for physician. 

Let’s also not forget the PC. You know, PCs are still important, even for those of us who are entirely mobile. I remember when the iPad came out, a lot of my friends were trying to become just the iPad and not use any other device. Most of those experiments have failed and they’ve gone back to using multiple devices. It is about the right device for the right place. We just have a lot more options than we had when it was either the Palm Pilot or a big desktop PC. Now we got everything that ranges from little thing in your pocket to a bigger thing in your pocket to a thing in your coat pocket, different slim levels of laptops all the way up.

It’s great to see all these different form factors and these different approaches. We continue to leverage them, and certainly that is a net win for physicians, because if they can have the form factor that works for them in their practice at the right place, that that makes it that much easier for them to become productive.

There is an irony to physicians demanding the latest mobile device to run 25-year-old software. Are you finding that the KLAS report that showed PatientKeeper well ahead of the core HIS vendors in usability is convincing people that to just run the vendor’s application on a mobile device isn’t really getting very far other than to make it theoretically portable?

Certainly things like the KLAS report that looked at usability of the PatientKeeper approach versus others is very helpful for kind of providing a third-party assertion of it. I’d like to think that when people look at running like a Meditech screen through Citrix on an iPad that they understand the difference between that and actually having a real-life application in terms of usability. I mean, it’s possible, but as you point out, pretty ironic to be running software that was written in an environment when there weren’t even laptops, much less iPads, and running them on your iPad. 

As we focus on usability and focus on physical productivity, you’ve got to get the right applications and the right devices. Character-based screens on your iPad is not the right application on the right device.

The KLAS report was unusual in that it almost touted PatientKeeper directly over the vendors that trailed behind. What has the result been?

We certainly got a tremendous amount of interest and excitement. People have been looking for an alternative to the problem that we’ve been talking about. Doctors are not excited about not getting benefits from CPOE in particular, and they’re being forced to use it. 

One of the reasons that compelled KLAS to look at this was, here’s a new thing. It’s very different. There aren’t a lot of vendors out there right now that have CPOE that sits on top of other HIS systems. The HIS vendors don’t offer their CPOE for other HIS vendors. It’s a pretty unique concept that we’ve spent a lot of time and a lot of money making work. Certainly I think it’s got a lot of folk’s attention, because it’s a solution to a problem that’s here today. We’re really excited to see the usability reports from physicians about CPOE being so high.

You mentioned the creation of an ecosystem of independent apps like in the Salesforce model. Where do you see PatientKeeper fitting into that or how do you exploit that if it happens?

We spent $100 million plus of R&D effort essentially making these HIS systems open, to us at least, with integration technology and a platform. We run our CPOE system on whatever HIS system is out there. There’s a lot of work that I won’t call proprietary, in the sense of it’s specific to a given HIS system. 

We are contemplating ways that we might make that technology available to the industry. Imagine another vendor that wants to build a really great system for a care manager in a hospital. They are faced with the same task that we just spent all this money doing, of having to integrate with all these different systems that are out there. We could make that available to them so they could do a bidirectional integration to the system and be able to spend all their energy on what they’re good at, which is understand the care management workflow at discharge time, and create a great application for them without having to do the work and break their picks on all the rocks that we did as we built that. 

Certainly it’s a concept that we’ve been contemplating. We haven’t done anything in terms of actually releasing it into the world. But to your earliest question about how do you create innovation, we need something like that to happen. Even if all the HIS vendors open theirs up, they’d open theirs up in a different way and you’d have a difficult and challenging problem. There’s real opportunity there, and I think it’s opportunity not just for one company, but for the industry overall.

If those vendors were threatened by your existence and your performance on the KLAS report, could they  shut off the data nozzle so that PatientKeeper couldn’t run?

It depends a little bit on what they would tell their customers about that. Technologically, there’s no reason why we can’t run nicely against their systems. Certainly there are things that people could do to make those things not work well. It’s not an environment that they would be very well-received by their customer base. Ultimately, this comes down to the customers. If the customers demand this enough, vendors will have to supply it. 

I actually believe, totally honestly, that this isn’t about us versus the HIS vendors. It’s about all of us trying to figure out how to automate the healthcare system in the most thoughtful manner possible. We don’t replace an HIS system, and in fact, we can’t run our software without an HIS system in place, because we don’t run hospitals. All we do is help the doctors interact with the hospitals in a more effective manner. 

We don’t even see the HIS vendors as competitors. We see them as very much complementary to what we do. And God bless them, I totally respect all the work they do to run hospitals and they do it very, very, very well. Hopefully they will respond accordingly and say, hey, look, here’s a great opportunity to make a bunch of doctors happy and make them more efficient and it doesn’t cost them a dime of revenue.

Any final thoughts?

It’s just great to get to catch up. It’s been almost three years since we last chatted, so I really appreciate the opportunity. And I really thank you for continuing to help keep the industry informed of all the great news. HIStalk is always the place that I go first thing in the morning as I drink a little tea and get going for the day, so thanks so much.