HIStalk Interviews Siva Subramanian, SVP Mobile Products, Zynx Health

Siva Subramanian is SVP of mobile products for Zynx Health of Los Angeles, CA.

Tell me about yourself and the company.

My background is in communications technology. I worked as head of product management for Nortel and Avaya, doing their healthcare vertical products, providing communications solutions to hospitals. That’s how I came across the challenges that hospitals faced in coordinating care. Communications was a big piece of this. They needed something more than just phones.

My wife, also the co-founder at CareInSync, was the head of quality improvement and also a hospitalist by training from UCSF and currently at the VA. Her area of research is care transition. That created a perfect storm for me to understand the challenges, understand the customer needs, as well as what the ideal solution could be like, which led to the founding of CareInSync.

Several companies are popping up to offer secure messaging and care coordination, sometimes both. How would you define the broad categories and positioning of competitors with ZynxCarebook?

If you can visualize, I draw a layered diagram. At the very bottom layer are basic communications. Whether they are phone or text messaging, whether it’s a secure text or not secure text, doesn’t matter. That’s basic communications that can connect one to many or one to one, most often one to one.

Above that, the next layer is the patient-centered team communications, which involves not just a formation of the team which is around each patient, but tracking of the work flows associated with each of those team members to keep the team structure integrity as the patient moves from one setting to another. That’s care team messaging and work flow that comes about.

Then on top of that, once we have a team that’s delivering care for a patient continuously connected to a solution such as ours, we can now direct evidence-based interventions based on where the patient is, where they’re going, what the roles of the people in the care team are, based on a set of content that’s been proven out, and work flows that have been proven to be efficient and effective. 

We need to have all three layers to deliver outcomes and improvement through healthcare organizations. If you’re doing just the bottom layer, which is what a majority of the basic secure messaging solutions do, then what you’re doing is trading off a phone for a text-based modality. That is an improvement, but it’s marginal at best.

When you talked about the interventions that are based on content and work flow, tell me what that means and how the acquisition by Hearst brings that together with the other elements that Hearst offers.

In my previous company, Nortel-Avaya, as a communications company, you could only do so much. You could replace modalities or perhaps make a more efficient connection. But that’s where you stopped.

To  go to the next level, you needed healthcare domain experience to understand the work flow of the 15-20 different disciplines of care team members that connect around a patient, depending whether they are in an acute setting, post-acute setting, or even at home. That required us to work through and work with healthcare organizations to understand that. Of course my wife was a key player in all this.

Then we leveraged a lot of existing interventions that have been proven to improve care transitions, like Project Boost and Project Red. We realized that if we were to grow beyond CareInSync, we needed a more sound footing and a credible footing in the clinical domain, which is to be able to leverage a much bigger bank or library of clinical interventions. That way we can direct all this information to the right people who are now captured by our solution.

That’s why the marriage with Hearst/Zynx became very timely for our group and an appropriate fit. It helped us differentiate from the lower-layer players.

What are examples of improving clinical outcomes from tying together communications, content. and work flow?

A very good example that ties all of these three layers together is a patient who is showing up at the emergency department. The patient’s being tracked by a care manager as part of an accountable care organization. The care manager has no idea that this patient has shown up at the ED.

Our solution can automatically alert when a patient tagged as high risk arrives in the ED. The care manager is automatically notified and brought into the team. They can now input into our mobile solutions key risk factors that they are aware of, which are very important for that ED doctor, who is only going to spend probably two or three hours with that patient and then they will either admit them or discharge them from the ED. That information and communication with someone who knows that patient well needs to happen in a matter of seconds, before the ED physician or nurse has taken some action on that particular patient.

Some of our existing customers have made a footprint in navigating the patient away from a high-cost approach to doing what that patient did not ask for versus what is a better approach for the patient preferred based on their choices of being DNR and things like that. They have had very real examples of cost savings as well as improved outcomes for the patient, not to mention better dignity of care for that particular patient.

A study just came out showing what most of us in healthcare already knew, that handoffs and changes in care settings are a big problem. Can technology and content be used to improve the handoff process?

That’s pretty much what we do. When we connect the things together, we provide a very concise set of assessment forms that gauge the barriers that this patient is going to have as a transition. For instance, from an acute setting to home. Those barriers then are married, if you will, to interventions that mitigate those particular barriers.

A good example is, if the patient has no transportation and lack of social support, meaning they live alone, then we automatically trigger a notification and invite a social worker into that patient’s team. This patient requires transportation to pick up medication, transportation to their primary care office. That connection is made in real time.

Normally this would require someone to make several pages and phone calls that may or may not complete and then the receiving person has to dig into the patient’s records to find all this information. We eliminate all that to make these interventions timely and for the right patient at the right time.

You saw the potential impact of mobile technology vs. desktop devices early on. What capabilities do you see in the future for using mobile in a clinical setting?

The two examples I described would be either sub-optimal or at worst not even be possible for a web-based solution, because as you know, they all require someone to be sitting in front of the computer looking at the information. The one thing that care providers lack into this environment — maybe two things, because technology is one — but the other thing is time, because they’re taking care of 20 different patients or more simultaneously. To change context in your mind around who needs what, you need a tool that can dynamically present to you which patient needs what in real time.

That push-based technology is going to become more and more prevalent. This is why physicians, if you’ve seen the stats, are moving to smartphones by the droves. They’re leveraging not just solutions, real-time solutions, but also just any type of content. It needs to be at the point of care, and most of the healthcare providers are rarely sitting down in a conference room discussing with other people.

A lot of the cost and the inefficiency of healthcare is trying to orchestrate the resources to be in the same place at the same time. Surgery is always a good example, where you’re trying to bring together a team, equipment, supplies, and the patient. Mobile brings people together. Are customers seeing job satisfaction improvement because people know where they’re supposed to be and when?

There are two types of scenarios. One is where there’s no other alternative, that the people have to be in the same place at the same time, as you described. Surgery is one.

Another example is where they wish they could be at the same place, same time, but they just cannot, like when you’re rounding on a patient. It’s very important for everybody to write their inputs, get the assessment that is interdisciplinary in nature, and then go back and take care of the patient based on their discipline. That’s very challenging in an acute care environment.

What we enable is a virtual huddle. Essentially, meaning they’re all connected around the patient. Assessments are kind of like a a very simple Google Doc for a patient. They’re real time, shared, simultaneously updated, and interventions are driven automatically. We help, with the mobile devices, alleviate that need for certain types of needing to be together and we make that virtual.

For others, a good example is a physician is talking to a patient. The patient may as a result of the conversation need to talk to some other discipline. With a real-time tool, you can pop open the patient’s page, see who the other provider is. Regardless of what shift or when the time of day is, you can instantly contact that person, and if need be, have them come to the room when the patient needs that.

Just-in-time care is going to become more prevalent. Care is going to become more efficient. Part of the reason is there’s no choice. Hospitals, if they don’t become more efficient, are going to be out of business.

I saw the product offers checklists. What are people doing with those?

Two things. When Gawande published “The Checklist Manifesto,” it made absolutely a very big splash. But if you read this book, he says two things — checklists and collaboration. Unfortunately, collaboration didn’t make the buzz when he published that book.

That’s what we bring together. We bring together a dynamic checklist that is driven based on the patient’s specific needs. We bring that collaboration, because the checklist filled by one person alone in the care team is not of any value if the other people have not read it and used it to influence their care.

By taking what would be otherwise a clickable form in an EMR or a paper form and making it a shared item that multiple people can simultaneously update and then it dynamically changes based on these rules and interventions that I alluded to earlier around that care team — that’s what really brings and makes an effective checklist.

What level of integration do you need to have to get other information sources such as the electronic health record?

At minimum, our product only requires a registration feed, an ADT feed. We require demographics information to identify the patient and to track as they move from different settings in the acute care environment or when they go into the post-acute environment. Beyond that, any other information that our tool uses is all entered into our tool because it’s primarily a very concise and very specific tool aimed at transitions, handoffs, and transfers.

You don’t need the mountain of information that’s in the EMR to make this process effective and efficient. There are specific touch points such as a discharge summary or an intake risk assessment. Certain customers have asked for that to be brought in, which we do on a custom basis. But the majority of our deployments are based on purely just ADT input. It’s a very lightweight input into our system.

Developers who are new to healthcare usually create an easy standalone application that doesn’t touch HIPAA and doesn’t  integrate with anything. What are the challenges when you’re trying to develop and support something that’s enterprise-grade for a healthcare setting and fully connected versus those simple standalone apps that work in their own world?

We went through this dilemma early on. Unfortunately, even the investment world has been caught in that bubble trying to invest in very simple applications, because they feel that that is something that can be understood easily and can grow.

Unfortunately, there’s not a whole lot of those type of applications that can deliver strong value and outcomes to a healthcare organization or even to a patient. That’s just the nature of the healthcare beast. If you’re selling to a hospital, you need a solution that is part of the work flow, even if it’s just a single discipline.

Like for instance, nurse. It’s very hard to do one slice of one small piece of a nurse’s work flow and survive as a company or as a solution. You may get few adoptions. No clinician wants to go to one place for certain things, then go to another place for certain other things.

Where some of this is being made easier or the barriers are being lowered is with mobile phones and tablets. Because of the push technology, the user doesn’t have to make a conscious decision to switch applications. The push can automatically present the information that they need to know at a given time. That’s alleviating some of this, but for a large portion of it, the applications need to be quite sophisticated and enterprise-grade with HIPAA compliance and other characteristics which makes it difficult for a start-up to scale without a significant amount of investment or being acquired. We chose a partner that can take us there. Zynx Health is ideal.

It’s difficult for companies to get a foothold. It’s tough to get a pilot. They have to compete for attention on the mobile device. They have to do some sort of outcome study or return on investment. Do you think it’s inevitable that most start-ups will fail and that those do succeed will have to be acquired to get critical mass?

I believe so. There will be many that are not able to even find that initial customer to fully deploy. Those that find it often flounder in the first four or five customers.

Once you’re over 10-plus, then you start getting that mass of implementation experience and references. But getting to 10 customers requires a significant level of runway because sales cycles in this world are … six months is a very good cycle, I would say. You have to have longevity or very significant amount of cash behind you from major investors.

Some start-ups have made it to that point — AirStrip is a good example –  but they’re going to be very few and far. A few of those will be acquired and then there will be many, many of those that just don’t make it.

What do you see for the future?

The direction we started out in fortunately didn’t require too many pivots to arrive where we are. Again, we’re extremely fortunate to find a partner like Zynx Health within the Hearst Health network that’s laterally aligned at the Zynx Health level, because care transitions and care continuum as well as just enabling team-based care for patients is a significant part of the Zynx Health vision as well, guided by evidence which they have gathered and are the market leaders. We are very happy to be part of that.

If you look at the Hearst Health Vision, this now takes us into the home environment, there’s the payer environment … Hearst has made investments into all of these areas. Under Hearst Health, now we’re able to share information across these portfolio companies to become bigger than the sum of the parts.