HIStalk Interviews Todd Fisher, CEO, MobileMD

Todd Fisher is founder and CEO of MobileMD of Warminster, PA. His blog is here.

Tell me about yourself and about MobileMD.

I graduated a long time ago with a degree in economics and moved to the Army. The Army was kind enough to pay for my education. In return, I repaid the Army by going on active duty as a communications electronics officer for a Special Forces unit. After that, I moved into the private sector and have spent the time since then in health information technology.

In 1997, I came up with an idea as I was working for a pharmaceutical company to Web-enable an electronic medical record. Today that doesn’t sound like a big deal, but in 1996-97, it was a little more progressive. I taught myself how to write software so I could prototype what I was thinking about. I got a contract that was large enough to allow me to go out on my own. I began a company called Intraprise Solutions.

Intraprise Solutions was, and still is to this day, a successful custom software engineering firm that deals in financial services and healthcare. In October 2009, we spun off the MobileMD division — which was the healthcare division of Intraprise Solutions – into its own company. We took in some venture capital and have been growing MobileMD quite rapidly since.

We’ve been in the health information exchange space as MobileMD or as Intraprise Solutions since 2005. That was when we went live with our first client, Centura Health in Colorado. 

We’ve done a very good job at taking our time to learn the special nuances and subtleties that exist between clients as you’re implementing full-service information exchange. We are SaaS platform. In going through that process between 2005 and 2009, we were able to gather a lot of information regarding what’s common and what’s different between every implementation.

In doing that, we were able to develop an understanding of what was productizable and what was something that would have to be franchised as mass customizable to bring us that last mile. It is part of our service offering to ensure that we not drop technology off the doorstep, but that we provide a complete and comprehensive service for our clients. That means everything from providing data analysis on the front end to delivering information directly into an electronic medical record established on the back end, not dropping off the results at the queue for somebody to put it away.

As you can imagine, given the disparity of systems and the myriad of different systems out there in the market, that’s a complicated task. We found we’re very good at franchising that.

How have HIEs changed over the last couple of years? When they first started, they were large-scale, questionably sustainable public utilities looking at very specific entities and a narrow list of exchangeable data elements.

There are certainly still public dollars flowing to help support and fund health information exchanges, but there has been a shift towards enterprise or private health information exchanges. That’s largely the market that we’re in. In fact, that’s almost exclusively the market that we’re in.

We’re finding that health information exchange is best served by serving a specific provider community and providing that community with a competitive advantage through health information exchange. Then, as patients transfer their care, patients become the catalyst to drive cooperation. The goal of the healthcare industry is to care for patients, so as patients move from provider to provider — in my world, from exchange to exchange – the need to cooperate is driven by the market, not driven from the top down through federal grants and funding.

I think the biggest shift has been a move away from RHIOs, a move away from forcing collaborative environments from the top down, and a move towards allowing market forces to generate the collaboration from the bottom up; creating what I would characterize as a network of networks with each little network being the health information exchange in and of itself. Then, connecting to other health information exchanges using some of the standards that have come out relatively recently from the ONC and are continuing to be developed by the ONC, those being an NHIN Direct and Connect.

That translates to much greater adoption. We have 28 production health information exchange instances right now serving 16 distinct clients. That counts Catholic Healthcare West as one client, but we are in 15 of their regions and each region is really its own health system. I will tell you that the private HIE adoption rate has been fantastic. If you compare that to the various state and RHIO-based initiatives that popped up between 2006 and 2009, I’d think you’d see a massive difference in the level of adoption.

You’ll also see a massive difference in the amount of information flow. We do about a million transactions a day through our health information exchange at our data center in Mason, Ohio. Those transactions include everything from ADT transactions to labs, radiology results, discharge summaries, CCDs — you name it. Any transcribed document, any type of clinical documentation, and some peer documentation is sent to our exchange and then distributed out to where it needs to go.

If you’re a hospital, what’s the biggest bang for your interoperability buck?

There’s physician alignment and fee-for-service. There’s a great desire for physician alignment, because if you achieve physician alignment, the physicians are actually your consumers, not really the patients. I say that sadly because the patient should always be the consumer.

But in a fee-for-service environment, the bang for the buck is alignment with the physician community. That is essential. If it’s easier to do business with the provider, then it generates an affinity and additional referrals to that organization. Simply put, you get your information back faster, you get it into your EMR, you get it available via our applications on the Web, whatever the case may be. It’s just easier to do business with that particular provider. It drives revenues.

Ironically, we’re equally effective in an ACO type of an environment where you have a population of patients that have a fixed amount of money that has been set aside, you have a team that is charged with caring for them, and they have a budget cap. They are to care for them in a manner that provides quality, but in a manner that also ensures efficiency. As a health information exchange that is capturing, centralizing, aggregating, and analyzing all of this information, we provide organizations with a great opportunity to launch accountable care initiatives. They are able to mitigate a huge amount of risk because of the sheer volume and accessibility of clinical information that historically hasn’t been available. Historically, the only information that’s been available is an insurance claim, which contains only a tiny portion of the clinical information necessary to make clinical decisions.

Who would you consider to be your most direct competitors and what distinguishes your offering from theirs?

Axolotl and Medicity. Both of them have recently been acquired by payers, as you know. That’s beneficial to us. It has been my experience that a lot of providers are a little concerned about doing business with health information exchanges that are tied at the hip with payers. 

They’re still definitely our biggest competition in the market. That’s the class that I would put us in. In fact, that’s the class that KLAS puts us in – not to do a play on words – and we’ve been very fortunate to have achieved a high ranking in KLAS and continuing to do so. The most recent scores I saw still have us pretty far out in the lead in the private HIE category.

Why do you think insurance companies are interested in HIE technology?

I had the unique opportunity to sit with Aneesh Chopra and Todd Park, the CTO of the United States and the CTO of Health and Human Services, respectively, at a dinner here in San Francisco. Interoperability, the ability to share information and not have that information locked in silos, is really viewed by pretty much everybody in healthcare as the only way we’re ever going to be able to transition the method of payment and the method of reimbursement in this country. 

Interoperability is a cornerstone of many initiatives. It’s the cornerstone of Meaningful Use. It’s a cornerstone of the Affordable Care Act, It’s a cornerstone of accountable care initiatives. It’s even a cornerstone of any kind of physician and patient alignment strategy that a provider may have. So you have interests in health information exchange companies from the outside, from all angles, from insurance companies that may find themselves playing in some way in an accountable care or capitated payment environment.

You also have a great interest in provider-type organizations that are concerned about their ability to share, communicate, aggregate, and analyze information that is available without having to reproduce that information, have duplicative information, inadvertently create duplicative tests and results, etc.

Every segment of the healthcare industry is relying upon not only the digitization of clinical information, but the sharing of that information. It doesn’t do much good if you digitize it if you can’t share it. A lot of it’s been digitized in lab systems and buried in lab systems for years, but it hasn’t been shared very well. It’s shared as faxes. That’s not very useful. Health information exchange is seen as a means to be able to provide that interoperability.

You mentioned Meaningful Use. What has been the impact on both the Meaningful Use requirements and the sometimes overlooked federal HIE grants on health information exchange?

The exchange of information is highly critical. Some of the Meaningful Use criteria includes being able to deliver to patients their protected health information electronically. That clearly is a role that health information exchange, particularly if it has a patient portal on top of it, can serve very nicely. If it doesn’t have a patient portal on top but can feed PHRs offered by WebMD, Google, folks like that, HIEs play a very, very important role in Meaningful Use in that regard.

The other area that I see that may even be more significant is as dollars are being offered as incentives to adopt electronic medical record technology in the ambulatory space, there has been a huge push to create lightweight electronic medical products. We’re proceeding in that directly lately, but that’s a critical component of our comprehensive solution. The reason that is that , even with all of the opportunity to collect funds over the years, there is concern now in the ambulatory space with respect to how EMRs are going to impact the operation of a physician practice, particularly if that physician practice is relatively small — three or four docs, which is the average size practice in the country.

All of the physicians in those  practices are looking for solutions allow them to achieve Meaningful Use, but they’re looking to newer, different solutions that are more cost effective, more rapidly deployable, or are easily supported. That’s where our Software as a Service approach comes in very handy. There’s no hardware, no software required at the site. You leave everything up to us. If you have any questions, you give us a call.

It’s interesting that EMR vendors are creating their own private exchanges among customers of their own systems, and then you as an HIE vendor are creating lightweight electronic medical records. How is that going to play out? Do you see yourself in competition with EMR vendors, or do you see yourself as the network they need to attach to?

You know what? That’s a great question. Let me state without question, we are EMR neutral. We are very good friends with several EMR vendors and we’ve integrated with certain vendors dozens of times. So I really don’t see us competing so much in the EMR space with EMR vendors.

We offer an EMR Lite simply because it makes logical sense. We have a clinician portal, we have a patient portal, we have all of the information for a community. We’re able to create a connected EMR Lite on top of that, if practices choose to go that route. Our EMR Lite will undoubtedly lack some of the sophisticated functionality that some vendors have spent hundreds of millions of dollars building, but it will be easy to use and it will be much more cost effective.

I think we’ll appeal to that segment of the market that has proven over the last 15 years they’re not going to buy an EMR. The EMR penetration is still very low, so I don’t really see us so much as a competitor to the EMR market. As far as their private exchanges competing with us, we haven’t really seen that at all.

Occasionally we are questioned about the community products that are offered by the likes of NextGen and eClinicalWorks and how that plays with our exchange, but they simply end up being a hub to which we exchange information because never — not even at an Epic site — never is 100% of the care community on the same technology, ever.

In fact, one of our clients is a very big Epic shop. We still have a role to play there because they still have large physician group — physician practices that are using other-than-Epic products in the ambulatory setting. They need access to the same information. Epic is listed in KLAS right under us as a private HIE, although it does clearly say Epic and Epic only.

We really don’t find ourselves competing too much with them, either. It really is one of these things where there are some economies that are able to be achieved because we provide one feed to one hub that then provides three instances of NextGen with data, as opposed to us providing three points. I would argue that it simply adds efficiency to the process.

When you think ten years down the road and we’re looking back, what do you think the impact of HIEs on healthcare will have been?

Ten years down the road? That’s a long time. I hate to imply a level of precision I can’t know, but I will say this. I believe that the ONC is starting to move very much in the right direction with regard to policy and guidance that they’re giving with respect to standards and how we’re going to build up a network of networks to exchange data.

I think we will see an environment in which the accessibility of comprehensive clinical information, regardless of where that patient was cared for, is going to be available, and it’s going to be available in one place, and it’s going to be very readily accessible. I believe that will result in significant reduction in unnecessary procedures, a reduction in medical errors, in poorly prescribed medication. 

I think that health information exchanges will be one of the catalysts to help alleviate so many of the problems that are outlined in Shannon Brownlee’s book Overtreated, playing a role in the massive and continuing increase in costs and healthcare simply because we’re making information that is so critical to decision-making accessible.

If you present at a physician’s office and you’re not able to articulate clearly all those things that have been going on with your health, in an environment in which physicians unfortunately have to protect or provide defensive medicine on occasion — without that information, they have to ask for procedures that may not be necessary or may have already been done. With that information they can avoid that and make much smarter decisions. It benefits everyone.

Without the exchange, the information simply sits in silos and we have a bunch of automated providers that don’t talk to each other. It’s like having one fax machine. Metcalfe’s Law, which is more metaphorical than it is actual, says that the value of a network is proportional to the square of the number of participants on it. One fax machine is useless. Two are a little more useful. Three are nine times as useful as one. The same applies here. 

That’s why we stay EMR-neutral. We want people to subscribe to the network. We don’t care why they subscribe, we just want them to subscribe to the network. Because when they subscribe, they’re providing information and they’re getting information, both of which are very necessary to the care for patients, especially in an environment where care is provided often primarily by specialists and not by primary care physicians.

What did being a Green Beret teach you about leadership and business?

I was communications officer in a Special Forces Unit, so I supported the A-Teams as they went out and did their missions by making sure that we communicated all the necessary information they needed to conduct their missions successfully, wherever those missions took them.

Execution is highly critical. That may be obvious, but all too often people don’t actually execute on plans. Execution is very, very important. Planning is very, very important. Quality of service is very, very important.

When you’re a Second Lieutenant and you show up at a Special Forces Unit, it’s made up of hardened senior NCOs. They’ve had every bit of special training that the Army has to offer. If you don’t provide them the best service possible, they will string you up and beat you like a piñata. I learned early on that service is differentiator. Anybody can build anything in this world, but service is the differentiator.

I also learned a great deal about sense of urgency — what’s important and what’s not important — and how to prioritize. In healthcare, when clinical information is flowing, it is important and it is urgent. Rarely does clinical information flow where it’s not important to get from Point A to Point B.

From a leadership perspective, I learned a great deal. My four years on active duty with the Special Forces unit taught me a lot about how to prioritize, how to strategize, how to look at the big picture, and how to marshal resources appropriately to get jobs done. Because at the end of the day, if the information doesn’t get from Point A to Point B, somebody’s going to get hurt, whether that’s in combat, training for combat, or in a care environment.