HIStalk Interviews Scott Shreeve, MD, CEO, Crossover Health

Scott Shreeve, MD is CEO of Crossover Health of San Clemente, CA.

Tell me about yourself and the company.

I am an emergency medicine physician. I was one of the co-founders of Medsphere, the first open source enterprise electronic health record. It was built and based on the Veteran’s Administration software system that was in the public domain. We had a good experience commercializing that software for hospitals and health systems that couldn’t afford the Epics and Cerners of the world. We had some nice success and early wins. I left the company under some challenging circumstances, but I’m thrilled to see it go on to be successful.

After I left Medsphere, I became interested in healthcare delivery and primary care. I was doing a lot of reading about re-architecting and designing new types of health services. I had read “Crossing the Chasm” and “The Innovator’s Prescription.” Primary care has always been such an important part of the foundation of a good, strong, healthy healthcare system, and if we could design that primary care foundation in a better way, with new payment models and a new care experience, that could be the basis of some great innovation.

After speaking, consulting, writing, and blogging about those topics for several years, I decided to take the plunge in 2010 to start Crossover Health. It began as a direct primary care practice. We had some initial success after opening up our first store in Aliso Viejo, California, but quickly learned that going directly to the consumer was quite challenging. We pivoted our innovative primary care model to address the needs of self-insured employers. Crossover became the medical group that provides services to companies like Apple, Facebook, Microsoft, Comcast, and others. We’ve been on quite a run since then.

Crossover Health describes itself as a digital-first national medical group. How does that work in terms of access, provider licensure, and use of analytics?

Crossover is focused on Fortune 50 companies and Fortune 500 companies that are looking to bend the cost trends in healthcare, that want a different experience, and that want to get more involved in healthcare delivery. They hire us to do that. We’ll come onto their campus or near their campus to build these health services.

What we find, though, is that most of the employers we work with have scattered pockets of employees all over the country. We were addressing only 10% to 40% of their populations by building near their headquarters. That was great for the patients who had access, but it didn’t address the needs or solve the problems of all of their employees. What they’ve asked us to do, and what we were doing on our own, is to extend our care model by adding digital-first as a strategy to capture the rest of the population.

That move is critically important. Telemedicine has been around for years. A remote employee in Georgia might work for Facebook in Menlo Park, but they can pick up their phone to immediately access their dedicated care team for the designated Facebook population and get the care they need right off the bat. We can either address is then or have them follow up locally where they live in Georgia with a curated network of specialists.

We have built a consistent care team that is licensed in all the different states. It is available to the people throughout the country who are covered by the benefits of that particular employer. Because we’re not physically in Georgia, we then have to steer, navigate, and coordinate the care for them when they access care that they may need locally. 

It’s an interesting solution. We either come on your campus or near your campus and provide a set of services, but now we are meeting the patients where they are, and that is digital-first. People are comfortable coming online. It’s  how they work in the rest of their life. Now we’re allowing them to work with their dedicated care team in the same way.

Surveys have shown that Millennials love technology and the immediate gratification it can provide, but don’t have much interest in cultivating an ongoing relationship with a primary care provider. How do you work with those employees?

I love the quote that “nature finds a way.” Everyone finds a way to get care. Millennials are comfortable getting online and asking things. If there’s not a coordinated, organized way in which that happens, they will meet their needs their own way.

What’s fascinating to me is that when you give them the opportunity to interact with a primary care physician and a consistent care team, they love it. It’s simple to them. They want to establish a relationship, but it has to be convenient, accessible, and in the way that they normally live their lives.

Our technology isn’t an electronic health record designed for billing. It’s a more like Slack, asynchronous communication with a consistent care team, where we can have that constant communication as needed. Then guide them in their local geography.

We’re finding that Millennials really do care about their health, but they don’t care for the traditional system that doesn’t provide access and tools. If you can meet them where they are, it’s very effective, very powerful. They are used to picking up their phone, logging into an app, texting their provider with a question, getting a response, and then digging in deeper if needed or being guided and steered to a local, curated specialty group. They are very comfortable with that. That’s not foreign to them, that’s expected. We are having a lot of success with that population.

Each employer has their own fingerprint and demographics. Some have older employees, such as in manufacturing and retail. We’re finding that those people very much want a relationship as well, and they are becoming comfortable with the tools. It’s almost like you are looking at different ends of the spectrum. You have the Millennials, who are very comfortable with the tools, and by the way, the relationship is great. On the other end, you have “I really care about the relationship,” and by the way, the tools are great. It seems like we’re crossing the generations through this type of a care model.

What are the contrasts you’ve seen as a former EHR vendor who now has the luxury as a provider to build the exact systems you need?

We’ve always had an electronic health record undergirding the foundation. But we built our own patient technology. Our patients never see the electronic health record. They see our tools, our patient engagement platform. With Jay Parkinson coming on board and all the work that he’s done at Sherpaa, we are building more tools and capabilities for our team members, our provider groups, to interact in this more asynchronous, structured question way.

Most of the care that we provide is through asynchronous means. Someone says I’m not feeling well, so we get orientation of what that is through this asynchronous communication. Once we’ve narrowed it down to a diagnostic category, we’ll send a structured question set, say, for stomach pain. Patients will take their time to answer that back. Based on that feedback, we’ll take the next step. We may need to see them in person and we ask if we can schedule that right now, or it could be that we suggest waiting for it to declare itself over some period of time.

We look at the electronic health record as the Slack channel. Each episode of care that we open up is its own project. We have tools that are effective at managing projects. Over time, we see replacing bits and parts of the EHR infrastructure with this patient engagement tool set because we are so focused on that. That’s where we see the evolution with Jay and with Sherpaa coming on board. Jay has taken on the roles of our chief designer and is building and extending what he did at Sherpaa, on a platform that has both a digital and now a physical presence. That combination is where he gets to play and innovate now.

Why is there a disconnect between widespread availability of virtual visits and the low percentage of Americans who have used them?

We are finding that it is not in the human experience, certainly not in the cultural experience in America, to get on the phone for 10 minutes with a random physician that you have no relationship with. We see 2% to 5% utilization. There are clearly situations where that is fine and where it works for the 30 set conditions that you can manage. What we’re really talking about here with our model is full-blown primary care that has, as its basis and foundation, a physical visit that’s done a little bit differently. Better, we think. But now purpose-building in the virtual connection as well and delivering it in the same way.

It’s a known care team that now has new capabilities. It can extend to individual patients and interact with them in the way that they do in every other aspect of their lives.

Traditional telemedicine — when it is disconnected, when it’s a random physician that you don’t have a relationship with, and when it’s not endorsed from your provider — is only going to have a certain percentage of pickup. Our thesis has been that you can develop trust in a medical group that is endorsed by your employer; that you have met, touched, and felt; and that now has the ability to extend the technology to you. That is really powerful. The person is at home and can access us. They know us. We get back to them. We’re on call 24/7. They have this connected experience wherever they are in the country. That’s the difference that we are banking and betting on.

How do health systems that make big money selling those questionably necessary visits react when you sign on with a big local employer?

Comcast / NBCUniversal is a huge player in all these different markets. Every health system wants to cater to their business. Our other employers are similar.

A lot of the health systems don’t really know what to make of us. If your business is built on sick care and you’re dependent on me feeding your MRI machine, that business model is doomed. The health systems that we do have a chance to work with are really innovative. They are very much based on value-based healthcare. They are realizing that while having a incredibly full hospital has historically been a big part of their business, I don’t really want that for the overall health of populations and value-based contracting.

We’re somewhat of a nebulous group to interact with. Some know that it’s a great model and a great primary care foundation, but it’s also challenging for them to understand how to work with us. Some innovative health systems know they haven’t been able to change the fundamentals of primary care in their own markets, so let’s do something totally disruptive outside of our system, but in partnership with a primary care group that is value-based and will send us the right referrals. It might initially look like that affects our immediate, short-term bottom line, but over time, given the new financial models that they’re moving towards, this is exactly what needs to happen, and they are embracing and endorsing it.

How much of Crossover Health’s identity do health systems use when announcing those services?

Most health systems have a lot of equity built into their brand from the trust and years and decades of work in that community. We have the option, and we do this with our employers as well, to white label our services, so it is very strong on that particular health system or employer’s brand. We can go all the way to the other end toward Crossover, because there are advantages to being totally separate, new, and different. In different settings, the privacy and the security and having a separate entity provided is useful.

We find that most strike a middle ground, where they want to have their name. but also our name together. It becomes a “powered by” situation. We leverage the good name and goodwill of that institution or brand from the employer, the health system, and then you can also show and highlight that you have this innovative collaborative partnership as well. That’s where we see most people land.

You’ve been out of health IT for a long time, but how do you see that landscape developing, especially with regard to what investors are funding?

This is like a view from 10 years ago since I left the industry when I was following it closely, but a couple of comments, maybe. One is that I’m surprised, but also not surprised, that Epic essentially has eaten the entire medical space. I think Judy’s concept of having a fully-integrated, comprehensive suite and then being able to get ahead of that is amazing. The value of the integration has been greater than any limitations of their underlying technology or otherwise. That’s been impressive to see from the outside.

Conversely, these monolithic kinds of system are incredibly hard to work with from the outside. It’s not that they are so technically hard to work with, it’s that they flat out don’t want to work or integrate with other people outside. That’s the negative side of how big they have scaled.

It’s interesting to see where Cerner has continued to evolve, along with Allscripts and others. I’m still a huge advocate of open source technology and love to see that Medsphere and others are out there still doing it.

Where my perspective has changed is that I see healthcare IT as simply a tool. Whether I have this tool or that tool, it is a tool that enables the information, the sharing of information.

The problem I see with health IT as it is today is that if architecture is destiny, then the way that these systems have been architected is highly concentrated around billing and other things. They have added other clinical components that are important, but that overemphasis and tying it to a fee-for-service system, which I also feel is doomed, impinges on the potential impact of where healthcare IT can go. What we are working toward and building is trying to get things that are more consumer-centric, where consumers can be more involved with their care, the record is really theirs, it is shared with their provider groups, and they have modern tools for interacting with their care teams.

Where IT has always been strong and remains strong is that you can aggregate the data, analyze it, and provide advisory services back to the people who need it, both providers and patients. I am pleased to see where that’s gone and where it hopes to go with machine learning, artificial intelligence, and other ways to introspect the data that has been gathered. That is really promising.

One of our big collaborators is Health Catalyst. Some of these big-iron tools that do deep-dive data analysis for big health systems are getting to the point where smaller providers like us can access them and put them to work. So much of our care is not about reacting to what’s on our schedule that day, but proactively reaching into the population to find those people who we need to be seeing that day. Then using digital-first tools and otherwise to get the people who maybe are less acute, but still have needs. Can we address those another way so that we can reserve the in-person visits or our concentrated efforts on those people who need us most?

How can technology overcome the fact that health system consolidation and the involvement of huge for-profit companies have left patients dealing with ever-bigger and potentially more bureaucratic organizations in their moments of need?

Privacy and the value of healthcare data is incredibly important. How you manage it, and the trust and confidence that people have to have and who’s storing the data, is critical. We work with some of the biggest technology companies with amazing amounts of data on different customers and the lives of all the people who use their platforms. We’ve learned a lot from watching how they do that.

There needs to be a role for a new type of health service that you join that keeps you healthy, that is independent of CVS, Walmart, and the insurance companies. People could join an organization that is purpose-built to manage their health information at their request. Who will be the first health banking service that is a trusted, independent third party that can aggregate your data and that you can assign in a permissioned way to allocate access to your data at certain points in time? Whoever creates that is going to be powerful.

The future health economy will be built on the currency of trust. One of the things that we sell quite a bit to our clients and employers is that Crossover is an independent, tech-enabled, data-enabled, national medical group that is independent of payers and health systems. We are a potential candidate to become that trusted intermediator of your health data. To bank your health data in a way that you trust and to allocate and invest your health information based the permission and rights you have. We are excited to see where that goes.