HIStalk Interviews Bob Katter, President, First Databank

Bob Katter, MBA is president of First Databank of South San Francisco, CA.

Tell me about yourself and the company.

I’ve spent my entire career in healthcare after business school. Some on the services side, but had a couple of startups, including RelayHealth that was part of McKesson. I’ve been at First Databank for 12 years, where I’m fortunate to have served as president for the last couple of years. First Databank has been in this industry, and evolved along with it, from the very beginning. What we do is pivotal. Any workflows having to do with meds — whether that’s ordering them, prescribing them, administering them, dispensing them — First Databank content is driving those processes for many users. We take our job seriously in terms of providing accurate, timely, and increasingly concise information that clinicians and others need.

One thing that I love about working here is that we work with people across the entire industry — the major HIT and EHR vendors, a majority of the nation’s health systems, PBMs, pharmacies, distributors, and the VA and government sector. The entire healthcare delivery system. As a company, we go beyond what we do today to industry challenges or problems where we think our footprint and our expertise can help.

How has interoperability across prescribers, pharmacies, and insurers changed over the past few years and where is it going?

It probably hasn’t changed enough. It is slowly evolving. It has always happened when it has to, but has been challenging.

For example, we have a couple of apps that run on the FHIR standard. That is the latest series of healthcare interoperability standards, at least on the clinical side. It is still more of a custom project as you implement the application with vendors than you would think it would be for the standards. 

There’s not a silver bullet, but we are going to have to get better in terms of interoperability. Some of it has to do with everybody having a silo. Vendors like us, information vendors, have our own proprietary identifiers, et cetera. We are all implicated in creating the system we have. We will have to push more standards, make them work better, and make them work more consistently. Otherwise, we will be regulated into it. But one way or another, it’s going to happen.

The industry has created electronic prescribing networks and entire companies that are built around selling specific technologies for managing prior authorizations and specialty drug orders. Will those offerings consolidate?

You have hit on a couple of important factors. There are a couple of dominant players, in terms of high market share, in a couple of aspects of that. You mentioned the standard NCPDP transactions and the prior auth. We think it should be, from the clinician standpoint, more of a unified workflow. When you prescribe a specialty drug, you have to do three or four things, in many cases, each with different parties. You have to do the standard eligibility and formulary check. Eventually, you have to transmit that prescription, but you’re likely going to do a prior auth. That’s usually a different workflow, and you’re likely going to do what’s called a specialty enrollment, which is yet again a different workflow.

Our vision would be that, from a clinician standpoint, you just order the script and then all those other transactions flow out of the back end of your EHR. You don’t have to go to a separate portal or initiate different workflows to complete all those other steps. That evolved because different things were tackled at different points along the chain. It’s not that any one company wanted to make it that way as much as that’s just the way the industry has evolved. But from a clinician standpoint, it’s not a very easy process.

Are insurers interested in making prior authorizations easier for prescribers?

That’s an age-old question. You can say yes from a simplification standpoint, and no if you believe that there’s a vested interest in having the drugs stall, even though if you look at the overall cost of care, there really isn’t. On balance, I think they have an interest in making it work better. I don’t think that there’s any technological barrier to having it all happen in a more electronic and automated way, not having to have all the phone and fax work. Certainly most if not all of the parties have a rationale in wanting to do that.

How well does the industry manage medication reconciliation and de-prescribing?

I don’t think we do it that well. Particularly among the Medicare population, does everybody’s med list make sense in terms of what they’re on, and in addition, what it says they’re on? I think that most clinicians who serve that population would probably say no. At that point, by definition, we’re not doing a great job. There’s a workflow challenge and a data challenge. You have to have the right people at the right time evaluating the meds that this this person on and what they need to be on holistically.

As far as the data challenge, even companies like ours have created proprietary standards that don’t always interoperate. Every system ought to be able to recognize meds from any other system, and that’s not always the case. There’s a way to solve that. It will have to be the healthcare IT vendors that are doing this, and hopefully they are going to work with terminology companies such as ourselves to make that better.

Some of the prescribing-related technology advancements came about after big drug chains got involved. Will the involvement of technology-savvy companies such as Amazon and Walmart accelerate the use of the technology you mentioned?

I think it could. I’m not sure they are bringing new technology, not at all to diss those companies, but I think they may bring pressure on the industry. If I can get healthcare at my local retail drugstore, and they can do a better job of figuring out which meds I’m on and which meds I shouldn’t be on, maybe that’s pressure on the rest of the industry to do so. I just read in HIStalk that Walmart is using Epic in their first five clinics in Florida. To the extent that shines a light on the rest of the industry that we need to do this better, that’s probably a good thing.

How do startups design their technologies around third-party information databases and services like yours?

We have a lot of startups come to us, along with terminology and  building block companies, but I don’t think they all do. We are doing quite a bit of work with some of the big tech companies now as well, and while this might sound self-serving, there’s a sense from the technology world sometimes that they have it all figured out. They may underappreciate the deep domain and content knowledge that already exists that might help them get to where they want to go faster.

Part of that is probably on us and companies like us. We don’t do a good job explaining what we do because it’s so arcane and domain-heavy. So, I would say we are doing OK. Certainly we get a ton of startups reaching out to us, and I’m always amazed at how much activity and how much innovation there continues to be in this market as new people come into it and trying to solve these age-old problems.

Do those companies understand why evidence-based guidelines aren’t universally followed by providers and that systems that don’t allow deviation from them won’t succeed?

Our company, as well as some of our sister companies within Hearst Health, are big purveyors of evidence-based information. A lot of us believe in that platform. But I think you are seeing a real evolution as traditional evidence-based healthcare collides with so-called real-world evidence. People are coming in from the outside and saying, if the real-world evidence suggests X, then what’s this “traditional evidence-based” thing mean, and how do those two relate?

On top of that, you have people saying that we can create this real-world evidence using AI techniques, derive its meaning, and it can be predictive on what to do. On that, I think clinicians are a little skeptical. They want to know the trail from how you got from A to Z. They’re not willing to just accept what the algorithm says.

If you say that we should return to traditional, peer-reviewed, evidence-based methods, and you’re not open to where the real-world evidence can take us, then you are ignoring a big part of the picture and where we need to go in the future. It’s in flux, but exciting for the industry. Ultimately, it should make it work better.

How much impact is pharmacogenomics and personalized medicine having now and how will it evolve?

I’m kind of chuckling because you could have asked me that question five years ago, and I hope my answer today is more accurate. Precision medicine, the idea that we can provide better guidance about this one patient — and PGX or pharmacogenomics is a big part of that, but not the only factor – is something that we and other companies have been pushing for a number of years, specifically regarding pharmacogenomics. We’re starting to see adoption. We have a partnership with Meditech, one of the major vendors, and they are taking that to market. We are inside several other major EHR providers and we are starting to have customers sign up and even ask for it.

I think we truly are on the cusp. We are two or three years out, I think. A lot of health systems, if they’re not doing something with PGX — particularly around areas like pain management or mental health meds, certain areas where there’s just so much evidence that you should look at that before you just prescribe drugs – I think we will see a lot more adoption. But I might have told you that five years ago and I would have been wrong. It’s a slow adoption curve, but I think it’s starting to happen.

The pandemic pushed providers into telehealth, some of whom lost access to the clinical tools that they were using in their EHRs. How has that evolved now that the telehealth urgency has mostly passed?

First of all, I don’t think telehealth is going back to where it was before the beginning of the pandemic. I’m personally a big believer in it, and that was way back about 20 years ago. The original mission of RelayHealth was telehealth. I think its time has come. I don’t think it’s going back.

I think you make an excellent point, and it depends on what you mean by telehealth. A lot of telehealth is  with your own doctor using the EMR system they use to document office encounters, so they are enjoying those tools. A lot of systems don’t have any of that, which presents two challenges. You may not have the tools themselves built in, so something around a dosing guideline or an interaction check, but those are pretty easy to provide, and people can incorporate those. The bigger challenge is that if you’re not running those tools up against the patient’s record with the fuller set of data, then they aren’t worth that much anyway.

All providers, whether they work for a distinct telehealth system or do video visits tied to the existing EMR, should have access to the patient’s basic record so they can run those tools and do those safety checks.

What factors will be most important to the company’s future over the next three to five years?

This is a great industry we’re in, and in that sense, it’s exciting. I’m grateful all the time to work in an industry that’s so meaningful and can have such a great impact on people’s lives. When you step back and look at what we’ve all just come through with this pandemic, the system did great at some things. I don’t think anyone thought we would have mRNA vaccines within 18 months. At the same time, a lot of issues will come out in terms of inequities, our public health system, and interoperability in how information was exchanged to help with the situation.

As I look at what’s important for our company, that vision you talked about is important. Precision medicine, personalized medicine, pharmacogenomics, pulling data out of the EHR to inform clinical decisions better and more precisely and much better. Not all the noise that clinicians see now, but specifically for this patient with this set of meds and labs, et cetera, what do we do? That’s great. When I combine that with what we experienced in this pandemic — and hopefully we are on the back side of that — that’s the right vision. We’re going to keep pushing that.

The science is advancing. AI is advancing. But we have to make it easier for clinicians to use. The industry, including us, has not done that as well as we could, and we have to make it broadly accessible. Information providers such as ourselves have a role in that, and all of healthcare does, but if we can stay focused on that vision at the same time focus on how we make it work for clinicians and ultimately for patients, that works.