HIStalk Interviews Sriram Devarakonda, CTO, Cardamom Health

Sriram Devarakonda, MSEE is CTO of Cardamon Health.

Tell me about yourself and the company.

I’m CTO and one of the founders of Cardamom Health. I’ve been in the healthcare IT ecosystem all my life. I was at Epic many years ago, then went to work for Microsoft in their Health Solutions venture. After that, at Nordic, and then then most recently and currently at Cardamom. I have a product, platform, and services end-to-end view of the world.

Cardamom Health is a data analytics and apps company. Our goal is to create this end-to-end focus as a company. A lot of organizations are great in certain verticals, but what it takes to drive change in healthcare is to use data, uncover insights, and use the insights to drive application and workflow optimizations. We as a company are doing that end to end. We are a two and a half year old company and are making some amazing progress in this area.

How will health system technology change as the move to the cloud continues?

We can learn a ton from established verticals like finance, retail, and manufacturing. As a consumer, when I’m spending money online, the scale of cloud computing allows sub-second fraud detection when my credit card is misused, content personalization, and cybersecurity analysis. All these things are happening because of the scale of cloud computing. Healthcare can learn from some of those established verticals.

My prediction is that since we’re starting an early journey of a full-on cloud migration, we will eventually be able to see greater resilience in terms of things like disaster recovery and the kind of cybersecurity we can expect with a hyperscaler that has thousands of cyber engineers who are working on a cyber threat analysis.

Those are two specific examples, but also this model of hybrid cloud makes it easier to connect to each other. You’re on one hyperscaler, you want to move data to another hyperscaler, and the speed at which interoperability can happen. These are things that I expect in healthcare. My hope is also the amount of innovation, the speed of innovation, that will happen to launch a basic VM, test something, deploy, fail fast, and move forward. Innovation will be much faster.

There’s also a cultural aspect. Workforce needs will change. Some of the traditional reliance on on-prem — database management, network administration, and ETL management —  some of it just goes away. Hopefully it is replaced with the need for somebody that is a lot broader in terms of cloud architecture, pure business analysts that can connect the different systems. Healthcare organizations will need to proactively manage that re-skilling and up-skilling in that hybrid cloud model.

How will health systems obtain AI expertise? Will they hire people, hire companies, or buy solutions?

We are working with many organizations, large and small. One thing that’s very clear is that everybody is in this mode of “necessity is the mother of invention.” Organizations are experiencing challenges with clinical burnout, which is a cliché term, but it’s truly happening at a scale that we have not seen before. Big, small, and in-the-middle organizations are looking at all options that are on the table to address workflow inefficiencies. I strongly believe that while everybody is going to buy — they already are buying from Epic or copilots from Microsoft – they are actively seeking out ways that they can take on very specific problems in those of areas. 

For partnering with someone like us, we understand Epic. We understand technology. We have our own data scientists. We can take some of those smaller or mid-level problems that nobody is looking at and go after them with some force.

My perspective is that everybody is going to do it. The real question is how much of that will last and how far they will go with that with the development. 

We also see the rise of low-code and no-core orchestration tools. There are amazing deployment frameworks out there and this democratization of AI. I’m looking at schools here in Loudoun County, where I’m from. Kids are coming out of college and high school with amazing skills in data science. It’s a lot more democratized than it was. Organizations will be comfortable doing more self-service AI and building their own AI tools, but they will absolutely buy as well. I’s a combination of build and buy, depending on how much build they can afford or how much buy they can afford.

Will we see some disappointment with health system attempts to apply AI to business problems that don’t create ROI? Are switching costs high enough that they will keep working on these projects, or will they just walk away and try something different?

It’s definitely a real challenge on how to measure the efficacies of AI agents, predictive models, and whatnot. People are still getting their heads around that. But there is low-hanging fruit. I have Microsoft, Epic, or Cerner. For me to adopt and take on their 50-plus models of the release out of box, and even go after those 50% of them that are around denials prediction, deterioration index, or the ability to respond to patient letters, these are straightforward use cases. If I can take off X minutes off every clinician, that’s value for them.

They are making some progress in some areas, not so much progress in the other areas, partly because of the efficacy of those models. Creating a framework for those, how to measure ROI and VOI, continues to be an interesting challenge. Somebody like us knows how to measure those workflows and improvements because we’ve helped other organizations do it.

How do newer technologies such as AI agents and model deployment via Nvidia Inference Microservices fit into the healthcare environment?

There are two parts to the question. First, agents or agentic workflows are already being deployed by all platforms alike. Some of these are what I call headless agents, where they’re doing some of that background agentic work, and some of that is UI app focused. They do very specific things, very singular. Some are multifunctional.

For us, the greatest inefficiencies lie in healthcare where you are collating information from X different areas — whether it is data from ERP and EMR — and then making sense out of it. Then depending on the kind of agent, whether it’s an information retrieval agent or an active agent that is making actions happen, is where the biggest needs are.

Every health tech vendor has agentic workflows at the core. The real questions over the next few years are some of the same challenges that we have seen in analytics historically — API access, data governance, what agents should have what access to information, and the lifecycle of creating an agent. That will become a process strategy question for organizations, because you don’t want agents to go do those things without other governance.

These are the challenges, but over the next couple of years, there will be this proliferation of agents across the board, just like when everybody wanted to do analytics and reporting. We have this bloat problem in the industry where the organizations have so much to do. How do you keep sense of what makes sense? Agents are here to stay. It really depends on the kinds of agents – tech-focused, back end, front end, and whether they act or retrieve all of that. But the value will be from their governance and change processes.

Will software vendors go beyond using AI to generate code and use it to change the functionality, appearance, or deployment of their products?

There will continue to be agents continue that are deeply ingrained into workflows such as Epic’s. You are a physician and you have an agent that does a very specific activity. Generating a progress note is one of them. At the launch of a quick voice command, some of that will happen. Those are deeply integrated solutions. But I also see external agents that harness and collate data from multiple sources.

It ultimately depends on which agents are natively part of your core workflows. If I’m a third-party vendor in value-based care or clinical research, I may need to do things to integrate with Epic and integrate that back into workflows. Ambient AI is great example.

Will companies try to add EHR AI functionality and hope that the EHR vendor doesn’t create their own version?

Take analytics as an example. A lot of amazing analytics work comes out of Epic, and lots of amazing organizations are using Epic’s own tools. But you still have these other organizations that have non-Epic analytics models. Is it the form factor of the external analytics tool? Is it the way that it’s integrated into Epic? Is it the flexibility of the UI?

If I were to build an AI tool to integrate with Epic, what parts of it can I do with my AI tool that maybe Epic cannot do, ever or in the short term? Short term in healthcare as 18 to 24 months. because the amount of innovation that’s coming is constantly changing. How do I manage that?

It’s a balancing act, honestly. I’ve seen organizations that have been in analytics for a long time still sustain because they constantly add some of the additional value. Ambient AI is a perfect, timely example today. Those ambient AI documentation companies do a great job when they have this bi-directional capability within Epic. I am a physician, I launch a note, I record a conversation using ambient AI on my mobile. As long as I deeply integrate within Epic workflows and to the exact same clinical note section, I have no dual documentation needs and no burden or extra steps needed.

But if I can’t do that, how good is AI? It will really depend on the bi-directional capabilities that I have the ability to do within Epic or Cerner or whatnot. But also the other things that I can bring to bear. If I’m a value-based care company, in addition to the ambient AI, I also have this external claims database, which is awesome, that I can uncover some of those notes.  It really becomes the question of, why will a physician, clinician, or nurse come out of their core EMR, and is that big enough for them to come out of the EMR?

In the early days of ChatGPT, companies rushed out wrapper-type products that were quickly matched by competitors or OpenAI’s own enhancements. How do companies decide whether to quickly release a product that doesn’t have a strong competitive moat versus hunkering down for long-term success?

I’ll give a slightly non-technical answer. I’ve been in healthcare for the last 20 years or so. With analytics, data platforms, and point solutions, why did some survive and others disappeared? Some lost their technical edge. They’re not innovative any more.

But overwhelmingly, I feel that some of them didn’t really solve the problem. They had technology, but did they enable the technology to the last mile? Do I have the combination of strategy culture as a company to continue to innovate and present that to organizations or to my users?

What I would tell those organizations is that technology is absolutely critical, but if you do not have the ability to figure out adoption, the enablement of all that, and constantly innovate in terms of other features you can build that maybe some of these other larger companies cannot be prepared, you are always at risk of being displaced. It is always the last-mile integration and constantly improving that for organizations.

What is an aspect of healthcare technology for which you have a contrarian opinion?

We are now close to 25 or 30 years of EMR deployments and digitization of records. Interoperability is still the same challenge. It’s not getting better, and all our progress has been incremental. We’ve gone from HL7 and came up with FHIR, which is a modern implementation of HL7 in its own way, more REST API based. But it’s all been incremental, and we have not really solved the foundational problem of interoperability.

I talk to any organization that’s in clinical research, value-based care, or even emerging fields like AI. Talk to any tech venture company. They still are clueless to figure out how best to integrate with not just EMRs, but with each other, with other vendors. The amount of work that has happened and we’re at a point where this incremental thinking of replacing one format to another is just not working to me. It’s destructive thinking. There has been a lot of talk about establishing national EMPI to reduce that data fragmentation.

Also, really, what is really interoperability this day compared to what was 25 years ago? There’s a lot more data sets that are interoperable, lot more fragmentation of workflows, and we’ve not really expanded the definition of clinical documentation to encompass everything that happens with a physician or a patient. Fundamentally disrupting that interoperability mindset is what I would say.

Will AI create a technical arms race where smaller companies can’t keep up, or will it instead give them a new way to compete?

It’s how technology has always been disrupted. Think of what Abridge has done in the last two years. Think of what ChatGPT has done. There’s still a small company.

Disruption will always happen, and my strong belief is that the next area of disruption will come from data creation, not data input. If you look at what we’ve historically done for the last 40 years, data input has always been text-based, whether you’re writing on a piece of paper or typing on a keyboard. But now we are in this early phase of disruption by data creation. The emergence of data input should not be by explicit text input, but by the product of human action, whether it is video documentation, wearables, or devices.

Innovation will come from smaller companies that are solving those problems around wearables, devices, and video documentation. Continued expansion of ambient AI is where that innovation will come. Small players can still disrupt, is my hope.

The amount of innovation that is coming out of EMRs and ERP systems is amazing, but some of this AI noise is also putting them on a back seat. We have to be careful about adulation of AI because AI is still new. It’s going fast, maybe much faster than anything we’ve ever seen, but it could also come at the cost of some of the innovation that’s already within the investments that you’ve made. Maximizing the usage of what you have is never the wrong strategy.

HIStalk Interviews Ed Gaudet, CEO, Censinet

Ed Gaudet is founder and CEO of Censinet.

Tell me about yourself and the company.

I started Censinet in 2017 to help healthcare providers deal with the risk around their third-party providers whether they be vendors, technology vendors, consultants, or any type of third party that could introduce risks into a health system. We have recently extended into the enterprise side of risk management, those areas of risk that are internal to a health system.

What type of risks are associated with third-party relationships?

If you look at the data that the American Hospital Association has put out and the OCR wall of shame, where they post the breaches and the data around cyber incidents in healthcare, you find that about half or more of these incidents are related to third parties. These third parties could be software providers, hardware providers, medical device providers, API vendors, or consultants who have access to the network. Any type of third party that is critical, or maybe even non-critical, has access to the network, or is working with the clinical data and or administrative data. They may not have the type of controls that the hospital has or the maturity of cybersecurity, whether their processes aren’t up to date or they are not  implementing the right technical controls to protect against attacks, data breaches, or disruption to critical systems. These third parties represent risk to a health system.

Does that risk change with cloud adoption?

Yes. It changes with any type of technology adoption. Those become vectors to attack. Look at AI. AI exponentially changes the attack surface. It will be the next frontier for cybersecurity organizations, security professionals, and risk management professionals because it’s the wild, wild West out there with AI adoption. We’re at the top of the first inning and we’ve got the first batter at the plate as it relates to AI adoption. It’s really early days.

We think of ransomware when we hear the word cyberattack, but what are other common methods that may not even specifically involve malware?

You’ve got the deepfake issue, which could be audio or video. Phishing attacks are going to get better and more accurate. I think they will come at us exponentially. The scale of the attacks, given what you can do with AI, is going to be much greater. We have to leverage AI for defensive purposes, not just for clinical use or patient care cases. We also have to look at it from a risk management and cybersecurity perspective.

I was reading that someone has developed AI that can mask foreign accents, and I assume it can also mimic anyone’s voice, both of which would take away one red flag about social engineering attacks.

Is this really Mr. H that I’m talking to today, or is it somebody else on your team? I guess that’s the point. How will we know and how will we verify these things that have been easily verifiable from an analog perspective, but now are now digital or electronic? It’s going to get much harder.

Imagine that your spouse calls you and says they need money because they have been abducted or has a flat tire and needs to pay the AAA person money via Venmo. These attacks are going to get more personal, and we are largely not ready for it.

How are health systems collaborating to share their cyberattack experiences?

One of the ideas that we had, looking at the state of the art back in 2017, was that there were a lot of manual approaches to risk management. We felt like there was not only an opportunity to drive automation at the workflow level, but do it in a way that gave leverage to the community. This is the guiding principle of how I looked at solving the problem. How do I give leverage back to the community that is managing risk on both sides of the transaction, whether it be the provider, the health system, the CISO, the CISO’s team of risk analysts, but also those third parties that have to go through that process of a security risk assessment?

At the time, everything was a point-in-time approach to a risk assessment. We believe that risk has a heartbeat and a life cycle. All  points from cradle to grave and in between represent opportunities for risk. You can acquire a product or service and have a good sense of the out-of-the-box risk. But what happens when you technically integrate and configure that product internally? You will have different knobs and you will configure it in a way that is different from the next health system. Those have to be considered. 

Then what happens when upgrades, patches, or new functionality are introduced? If you look at AI as an example, everyone is thinking about AI coming into the organization from the front door. I think the bigger risk is it coming in through the window, through the back door, or through the basement. You have all of these technologies in play and being managed, and they are introducing AI into their products through upgrades, point releases, or patches. How can health systems and CISOs keep up with new risks that are introduced not just via adoption or acquisition, but also through the implementation, configuration, and usage?

We’ve seen plenty of scenarios where a product was acquired to solve a specific use case that did not require protected health information. Then users got their hands on the application and started leveraging it, maybe in ways it wasn’t designed to do, such as including PHI. All of a sudden you go from a non-business associate to a business associate relationship. You don’t have all of the protections that would be in place in terms of a BAA being signed, or any of the insurance obligations that a BAA might have to take on, because the initial intention was this different type of relationship.

What are the lessons learned from the breach of Change Healthcare? It was a critical supplier to health systems and a new acquisition for UnitedHealth Group, which said it found out afterward about Change’s security deficiencies.

It goes back to this lifecycle approach to risk versus a point in time. During the lifecycle, during the relationship that you have with a vendor and the product set, there are plenty of opportunities to introduce risk. One of those is ownership.

When I was at ViVE last year, I was speaking to a couple of customers as the breach was announced. They said, “We don’t use Change Healthcare, so we’re good.” Within 48 hours, they realized that they actually did use Change Healthcare through an acquired product that they relied on. 

There’s always danger of that introducing new risk. That risk is around concentration. You have a critical function in your organization, a business process that is directly linked to your ability to collect revenue. All of a sudden it shuts down and that spigot is turned off. Now you have operational disruption. You only have so much cash on hand. That was another big aha. We have to deal with all that disruption, but we also have limited cash on hand. We can only sustain operations for a certain number of weeks.

Complacency set in. We got comfortable relying on one vendor over time to do a very critical function. In fact, we may have created that scenario, because we may have signed up for exclusivity clauses and contracts. There may have been an exclusivity clause that required us to go all in with a particular vendor. That sounds good on paper until something like this happens. Where you haven’t built up a resiliency plan, you don’t have continuity in place. You haven’t thought about alternatives that you may need to activate in the event of an incident like Change Healthcare. A lot of lessons came out of this incident.

What advice would you give a hospital CEO about vendor and supply chain risk management?

People tend to confuse these two areas. Vendors tend to be supportive of a particular business process, whether it’s a critical clinical function, an administrative process, or an operational process. If you look at health systems today, every organization and every department leverages a technology-based business process. I can’t think of another function that isn’t relying on some technology to meet its goals and objectives in support of the company’s growth or other mission. You also realize that there are opportunities where you need to include certain components in the things that you create or deliver as a service. Think of them as ingredients. I think of a supply chain as those things that I need to create my end service or product. That’s how I think about the difference between those two things.

Do you see an opportunity to use AI to further develop your offerings?

Absolutely. In fact, we made a couple of announcements at ViVE. We’ve been working with AI for the last couple of years. We took a conservative, responsible approach to it because we’re a risk management company. We have to put security first for our customers.

For us, it was all about identifying those use cases where we could drive efficiency of process.  There’s a lot of process automation and solutions that AI can enable through making things faster, better, cheaper.Then there’s the whole data aspect of AI. What things can we learn from the data? What insights can we gather that we couldn’t because we didn’t have these language models that would enable this in a way that was truly, truly scalable? 

We’re applying it in those two ways, generally speaking. We also took a step back and thought about how we would apply it to our product sets.The first thing we did was create Censinet AI, which is a foundational set of services that are secure, proprietary, and native. We don’t rely on ChatGPT or any open API language models. They are all built on the AWS stack. We went all in with AWS, Bedrock, and Anthropic Claude and their models. 

That architecture enables secure capabilities that can be turned on by demand by customers. Customers can opt in to choosing to activate to turn on those capabilities or not. They can do it based on their appetite and also their timeline. We have some customers that are ahead of everyone else, and they want to jump right in with AI. They trust us to protect the infrastructure, so they are going to turn them on quickly. Other customers will go slowly and turn them on over time as their governance processes mature.

Vendors are coming out and saying, hey, we have a solution, and it’s all AI based. We think that’s a failed approach, and people are going to get into trouble. We think that  the approach to be more prescriptive and controllable by the end users is the way to go.

How do you expect the federal government’s role in healthcare cybersecurity to change under new leadership?

Censinet has been at the forefront of working the HHS 405(d)  initiative and with the Health Sector Coordinating Council on things like the landscape analysis that we worked on in conjunction with CMS to create the cybersecurity performance goals, which came out of CISA. We thought those would be the foundation for a standard that health systems could actually adopt. I called it Meaningful Protection, analogous to Meaningful Use. Can we create this level or threshold of protection that we can all agree on. that is affordable, and could move the needle on patient safety?

That all was heading in the right direction. They realized last year that because the Cybersecurity Performance Goals were voluntary, they couldn’t be turned into laws. They needed another vehicle, so HIPAA was opened up. A comment period was started based on a HIPAA proposal a new rule that was generated. The administration change risks that being slowed down significantly or being canceled altogether. We’ll have to wait and see how it plays out.

But to your point, there’s a lot of movement in all of the different agencies. CISA lost a lot of their leaders and also risks being completely shut down, which I think would be a disaster. HHS has lost a lot of great leaders like Micky Tripathi and Nitin Natarajan. Between CISA and and the people at the HHS, we’re taking a wait and see approach. We’re going to continue to move the process towards the extension of HIPAA to include the CPGs or the intention of the CPGs.

What factors will be important parts of the company’s strategy over the next few years?

We continue to evolve the platform. We have over 50,000 vendors and products on one side of the network. We have a couple hundred providers on the other side of the network. We continue to build the product to address new use cases.

AI is a particular area. Not only are we have invested in our infrastructure and our product set to bring these AI features to market, managing the risks of AI as core to the product as well.  We have capabilities that enable AI governance through workflows and through content curation. On the vendor side of the network, we leverage the data in a way that enables these third parties to assess their protections and their security in an AI context.

We will continue to move the needle for our customers, both the third parties as well as the providers. We are also excited about agentic AI and what that can bring to the table in the longer term. We recognize that there’s a lot of unknowns there and there’s a lot of risks associated with agents going off and not only identifying relevant data, but then turning that into action and conducting the action on behalf of humans. We think that is coming and we need to do it in a secure and a responsible way.

HIStalk Interviews Stuart McLean, CEO, Nordic Global

Stuart McLean, MBA is CEO of Nordic Global.

Tell me about yourself and the company.

I’ve been in healthcare for about three decades now. I started by doing merger work for what is now Northwell. I did that for half a dozen years as we built that system, which led me to have a deep appreciation for the importance of scale and operating efficiency. I co-founded my own turnaround firm and merged it into Alvarez and Marsal. I’ve been focused for the last couple of decades on strategic financial operational strength for healthcare providers.

Nordic has been in place for about 15 years. We’ve greatly evolved over that time. We have a handful of areas of strength, certainly EHR – Epic, Oracle, and Meditech. We are increasingly working as implementation partners for Workday and Infor and seeing that as an important part of what our client healthcare systems need.

We’ve also developed a real strength in cloud, working with our partners AWS and Azure. The healthcare industry is moving to the cloud, at least on a hybrid basis, so it’s an important question about how best to do that. Finally, I would want to highlight the transformation that we have taken on to move in the direction of a full-service, end-to-end managed information technology company for our clients.

How do you characterize the health tech consulting market and how do you differentiate Nordic within it?

I think it’s getting increasingly crowded. Private equity views this as an important part of the healthcare transformation, so there’s a bit of a rush into this business.

We have maturity and a deep team. We have 3,300 professionals who have been at this for a while. We began 15 years ago with a deep expertise in the implementation, optimization, and integration of EHR systems. We think that makes a significant difference.

What are the benefits and drawbacks of being such a large organization that also provides services in Europe?

The expansion into Europe has been interesting. We operate in four countries in Europe — England, Ireland, Switzerland, and the Netherlands. We are growing pretty rapidly in that market as those markets recognize the benefits of the EHR platform as part of their strength. Because of our focus on managed services, we do a good bit of outsourcing work both in Ireland and in the Philippines.

How far along is the move to the cloud? Are health system worried about the cost or vendor lock-in?

This is a very early game. We just published an e-book that is available on our website where we dive into that a little bit deeper. We think it’s important to have a comprehensive evaluation so that we understand the benefits from an integration perspective and the concerns with regard to security since health systems are, and should be, risk-averse with regard to patient care information. That’s an important element of the response that health systems must make to the financial pressures that they are feeling.

Oracle Health has a lot of resources when it comes to cloud and technology and general. How will that influence its position in healthcare?

We are all going to benefit from that competitive dynamic between Epic and Oracle Health. Each company comes from a slightly different place. Both companies see the massive market size here and are pursuing it. They are pursuing it thoughtfully. I don’t pretend to have a clear crystal ball into who will be the winner here. They both will survive. They both will thrive. Here again, the health systems will benefit from that kind of competitive dynamic.

How much do health systems margins, M&A, and changes in staffing patterns affect your business?

As somebody who knows the health system industry really well, I’m surprised at the government’s response to the desire and the need for scale with health systems. I’m really surprised by it. When you compare UnitedHealthcare or any number of these large, national, fully consolidated insurers and the desire by the US government to keep healthcare pretty fragmented, it makes the work that Nordic does even more important. Those health systems are simply unable to access the scale economies that they would if they were allowed to be $20 to $50 billion super-regional health systems. We at Nordic can deliver the benefit of that scale.

How are health system IT departments affected by cloud adoption and the challenge to find and keep employees with specific skills?

It’s a little overwhelming. Without naming or getting into any competitive information, we have clients who are very concerned about the competition for their IT talent.  That’s where I think we can be beneficial, because of the size that that we have, for those clients that choose to establish an outsourced relationship with us.

Two things happen. One, they no longer have to worry about access to talent, because we have it on a national and international basis. Secondly, we think we’ve struck the right mix of offshore, lower-cost delivery and onshore capacities.

Will the shift from onsite consulting to remote services last?

I think so. I’m an individual on this question, but also we at the leadership level have given some thought to this. We see efficiencies from non location-specific delivery of these services.

Will AI change your business?

For AI adoption to be successful, it’s a balance. It’s technology, but also humanity and empathy. The focus in the health systems space today is principally around decision support, predictive analytics, and workflow optimization.

We don’t see a revolutionary impact in the near term, in the next year or two. To your earlier question, with regard to Epic and Oracle, those organizations are spending a tremendous amount of energy and effort in this area and are working with early adopters to beta test and refine these capabilities.

I think the AI promise is very real, but it’s more likely three to five years away than one to two years.

Will it deliver tangible ROI to health systems in the short to medium term?

I don’t see it in the short term. I’m not even sure that this will ever be an ROI topic for health systems. It’s about the quality of care and population health, with the ability to become more proactive, more targeted, and more precise with regard to patient- specific situations.

How much of an AI driver is clinician satisfaction and wellness?

It’s not a primary ask from our clients at this point. It’s a bit more of an evolutionary component of this. The clinician and physician wellness part of it will be supported by the healthcare heuristics element. Have you asked this question? Have we considered this diagnosis? Rather than the AI providing the answer, it will offer help with going down the decision tree in the pursuit of the answer.

Shifting to business climate, what kind of companies will be winners and losers now that cheap financing is gone and investor demands have changed?

I think there will be a fair bit of chaos in this space. Nordic is in a very strong position. W are owned by Bon Secours Mercy Health, and their ownership interest is strategic and long-term.  We’re not worried about capital structure and those sorts of things. We are focused on the strategic value of the work that is delivered by Nordic to our clients. We have a longer and more patient horizon, and that will make us stronger over time. There is money pursuing quick earnings, and this business requires patience.

Does General Catalyst’s acquisition of Summa Health foretell significant industry change?

I don’t follow General Catalyst closely, but I’m aware of that situation. I think they see the health system ownership as platform, almost a laboratory, for innovation that could then be deployed and delivered to others. I think that Bon Secours Mercy Health is in a better, stronger position as an independent, not-for-profit. long-term that’s less interested in capitalizing and creating dollars than they are in supporting the quality of care over long periods of time.

What factors will be important to Nordic in the next three to five years?

Strategic partnerships with other large health systems. We’ve been a contractor and we remain a contractor, largely. We’re hired by a health system to run a project to implement the EHR or optimize the EHR. We see our benefit increasingly in long-term, five-plus year agreements with health systems to be their technology partner. Not developing technology, which is the role of Epic and Oracle and others, but managing that technology cost-efficiently because the pressure is real. We think that we can be worth 25 to 30% over time in terms of the technology spend while still ensuring a strong, durable, consistently available platform.

HIStalk Interviews Jason Rose, CEO, Clearsense

Jason Rose is CEO of Clearsense.

Tell me about yourself and the company.

I’m Jason Rose, the CEO of Clearsense. I’ve been here about a year. I’ve got 30 years in healthcare technology. The first half of that was on the healthcare technology side of provider, working at companies like Cerner, Ernst & Young, and Ardent Health Services. In the last 15 years or so, I’ve been mainly on the payer side, focusing on value-based care and providing tools to clinicians to advance outcomes. Inovalon and Adhere Health are a couple of those companies.

I’m excited to be with Clearsense. We are a data-enabling platform company that focuses on supporting health systems to revitalize their data for other use cases, such as reducing costs in areas such as application decommissioning, or advancing other areas of innovation, such as healthcare data lakes, clinical trials, research, and AI validation.

Who do you see as your competitors and how are you different?

Because we’re a broad data-enabled platform company, our modules have different areas of competition. 

When we’re talking about application decommissioning — we’re more commonly using the term active archiving — we are competing with companies that operate in that space as a SaaS organization. We don’t compete with companies that do, let’s say, application rationalization. In fact, we partner with companies, consulting groups, that do application rationalization or that put in governance programs so that we can exploit the value proposition to scale the decommissioning of applications that are mired in most health systems of today due to all the mergers, acquisitions, and enterprise rollouts of EHRs and ERP systems.

We’re on KLAS. We have fantastic ratings. We are on record as the largest decommissioning project ever, per KLAS. You’ll hopefully be seeing some news on that in the coming days with respect to this massive installation of literally hundreds and hundreds of different applications and several tens of millions of dollars in cost takeout.

On the data lakehouse side, we will compete with middleware companies that are taking data in from primary sources, EHR companies such Epic, Cerner, and Allscripts. Think about archiving, systems that are shut down or systems that have been around for 20 years or longer. We’re pulling in longitudinal data and as near real-time data as the client wants. We’re certifying that the data is exactly accurate to the data source. We certify it with DAV, Data Aggregator Validation, which is an NCQA certification program that matches the data we got from the primary source, whatever EHR system, with our new data lakehouse to make sure it is identical and complete.

We are taking in multiple EHR instances across the entire health system. In some cases, it could be dozen or dozens of instances that we are patient matching  across the entire enterprise. When the client wants to bring their own technology, such as their own AI methodology, proprietary tools, data visualizations, or different types of areas of LLM, they can do that on top of our data enablement platform. We are enabling them to do all those things in rapid fashion.

Some people might see decommissioning as just converting whatever data you can to the new system and then leaving the old system running somewhere just in case. What expertise is needed to do it right?

We are, I would say, the expert’s expert in doing this at massive scale. Health systems are commonly doing mergers, acquisitions, rolling out EHRs and ERP, or trying to improve their cybersecurity posture. All of those are critically important today. 

The reality is that in the application portfolios of these systems, they have done the app wrap programs with lots of consulting firms over time. What they haven’t done is look at how to do this at massive scale across all the different areas. Having the SaaS program that we deploy, the consulting, and the expertise, we put together governance programs that are partnered with the executive leadership of the health systems.

These are not IT projects, these are business projects. This is going to include not just technology, but also clinical, HIM, finance, procurement,  the legal team, and the operational areas of the health system to take the applications from the app wrap program and prioritize — with everyone putting their hand on the stone, so to speak – to say, we’re going to decommission these dozens, hundreds, or in some cases, thousands of applications. 

Most of these health systems have 20 to 30% bloatedness, that’s the term, in their portfolio. The massive amount of cost takeout and cyber improvement is huge if you are deploying it in the right way. Cross-departmental as a business problem, as a cost takeout, and cyber improvement, but it needs to be multi-departmental. It’s not something to take lightly.

It really is a company mission, and our best examples where we have done this really well was where it was a mandate from the top down that said, “We’re going to do this as a health system and make it a priority so that we can reduce our operating costs. These are hard numbers. We can improve our cyber posture.To realize the benefits that the EHR system represents, to represent the ERP system enterprise value, or the M&A transaction.”

This is all about acceleration to value. We see ourselves as the pioneer in this advancement.

Do increased cybersecurity concerns bring in clients who need help, but who also want to know more about how you will protect their data?

A lot of these systems that need to be decommissioned may not even be supported by the vendor at this point. Or they could be homegrown, which is even worse. Issues such as cyber threats are at the top of the list. Some people call them zombie apps. These are the easier ones, you know, but they are still there.

Once decommissioned, the data is processed and stored securely in our HITRUST- and SOC 2-certified cloud environment. The data is immediately placed in a safe and secure environment because of the nature of where it came from and where it’s going.

Does AI create new business opportunity?

I’ve historically been skeptical of any new acronyms that have come out in our healthcare industry. There has been so much hype around the next big thing, and then it fizzles out. Healthcare is just different from other industries. We’re much, much slower to adopt, for lots of good reasons and lots of bad reasons, too.

But I will say, and this is literally the only time my career that I have said this, that I think AI is legit. I did not say that about blockchain, big data processing, or all these other things that have happened over the last 20 or 30 years. I’ll even go Y2K. But I think AI is legit. 

As a company, we are looking at how to apply AI to writing code more efficiently, processing data faster, and ingesting data differently. We are exploring different areas of how AI can help make us more internally efficient so that we can drive value acceleration, which is what our brand is all about.

But on the flip side, we’re a data enablement platform company, so we look at AI as an opportunity to add a value proposition in things such as enabling our clients to incorporate their AI onto our data platform. For example, we have a significantly large health system that we’re in the midst of bringing live. We have millions and millions of members that are across a dozen or so EHR instances. It’s longitudinal back to 20 years and up to three days ago. It has completeness, timeliness, and the data is certified.

The client is putting their own AI tools and their own proprietary tools on top of our data platform so that they can run their own algorithms and test other technologies and initiatives that they want to do, both within their health systems and also across their their other ventures. It is helping them advance in a rapid, scalable way to be free to explore and create their own mission. We are the enablement aspect of that.

As someone who has been in health tech for a long time, how do you see today’s environment and how it might change in the short term?

I’m going to quote Stephanie Davis, who is a Barclays analyst, from something she said last year. We have the ViVE conference coming up here in Nashville, which is our new corporate headquarters for Clearsense, but at last year’s LA ViVE conference, a question from the audience asked Stephanie, “What are your thoughts on AI, and how many of the companies on the floor of ViVE you think will exist in two or three years?” Her response was astounding, interesting, and I agree with it. I think that it will be a single percentage left in years to come.

You will have all these different AI companies that are hyper competitive with each other, and only a very few of them will actually exist in years to come. There’s a lot of hype around companies that claim to be the next big thing on AI versus the commodity of AI,  AI itself. There will be a lot of churn in areas. We are not trying to be the AI company. We’re trying to be the enablement of AI. I predict that we’re going to see a downfall of a lot of hype and investment in these AI companies, because they’re going to eat each other.

The other prediction, and this is sort of Captain Obvious, is that if you’re not focusing on your clients’ value proposition as your core mission, you will have a hard time succeeding in today’s environment. It’s no longer where private equity and venture capital will support hype. They need growth, profitability, and sustainability. These companies that are just built on hype won’t exist. You have to have real tangible value that you can point to. Not actuarial madness, but actual hard dollars that your clients will tout, including the CFO of those companies, to say that this is actually a tangible ROI that I received out of this company. Without that, a company is in trouble in this hectic time.

How has the health tech business climate changed in Nashville?

This is the second time that I have moved to Nashville. The first time was back in 2002, when it was the country’s best-kept secret. Now the secret is out and is no longer a secret. 

A lot of people consider Nashville to be the healthcare tech capital of the country. A lot of people consider that the Silicon Valley of healthcare technology is in Nashville. If you look at the core of this environment, almost all, if not all, of the large for-profit health systems are headquartered here in Nashville. The most dominant industry in Nashville and greater Nashville is healthcare. Because of that, there are dozens if not hundreds of companies that are focusing on innovation in healthcare and driving healthcare technology strategies. Companies like HCA, which is the largest health system in the United States, Ardent, Lifepoint, Community Health Systems, and all those large companies. 

Because of that massive amount of economy here – I think it’s around $100 billion coming out of Nashville alone, which is just a fraction of the valuation of those companies — this is the nucleus of the country. That’s why ViVE is coming here every other year, and that’s why it’s gotten so much accolades. Oracle about a year ago announced that they are relocating their entire corporate headquarters to Nashville and they are in the midst of doing that right now, downtown next to the new multi-billion dollar Titans stadium. Amazon announced years ago that their eastern service excellence headquarters moved here as well. 

This is a big tech hotspot now, and also healthcare is dominant. We’re happy to come back here and I wasn’t moving, so it was easy for me to make that choice. It was from a company standpoint and the fact that I love this town and the culture. If you’ve never been to Nashville, it’s an awesome town. They call it Nash Vegas for a reason. It’s one of the best places to go in the country, with food and entertainment, and is very rich in healthcare as well.

What excites you most about the next five to 10 years in healthcare?

I go really way back. I got a graduate degree from the George Washington University School of Business. When I went there in the mid 1990s, there was no healthcare tech program. That didn’t exist. I was asked to choose a discipline of focus in my Master’s of Health Services Administration degree. I said, I want to do technology. They said, that doesn’t exist. No one’s doing that. It’s either acute care or regulatory compliance. I said, no, I want to do healthcare tech, so they allowed me to create my own custom degree. I’m actually the first graduate intern at Cerner Corporation. I may be the only graduate intern, but I was the first graduate intern for sure [laughs]. That set forth the last 30 years of where I am today. 

What I am most excited about goes back to where I was in the 1990s, where I saw the promise of technology, data, and analytics advancing healthcare in helping drive us to better healthcare outcomes, higher quality and healthier lives, and increased efficiency and reduced cost in healthcare delivery. I have about equal parts of a provider and payer experience with a dabbling of life sciences, so I’ve got a pretty broad spectrum of my foundation of experience. I have never been more excited than right now about where we’re headed over the next five or 10 years.

AI is definitely a big part of it, but not the only part of it. I could not be more excited about where we’re headed because of the massive adoption we’re finally doing in health care tech. I think it’s real this time.

HIStalk Interviews Erine Gray, CEO, Findhelp

Erine Gray, MPA is founder and CEO of Findhelp. 

Tell me about yourself and the company

Findhelp is 14 years old, based in Austin, Texas. We focus on simplifying the way that people find and enroll in social services in the United States.

Our company’s history began with the realization that understanding your options in times of need is not easy. We started by building a search engine that allows people to put in their ZIP code and find available social services, such as affordable housing, food, or even programs that are available through public entities, such as the federal government and state government like Medicaid, Temporary Assistance for Needy Families, Children’s Health Insurance Program, and the Supplemental Nutrition Assistance Program. Our platform supports many of the 1115 waiver programs in the United States, which are experimenting with allowing social services to be paid for with Medicaid dollars. We are doing that work in New York, California, and in other states throughout the United States and plan to be doing more in the coming years. 

The goal is that people will find those services and then click a few buttons to apply and get enrolled if they qualify. Once they do, we’re the largest closed-loop referral platform that allows people to circle back and say, yes, I did receive these benefits. 

Our customers hope to see whether these interventions improve long-term care. We are a full-stack platform for allowing that to happen. They will be able to see what actually occurred from the very beginning, when they were searching Findhelp.org to find a program, to the very end, once they’ve received the program and interacted with their health plan, the health system, or other community organizations. The goal is to study that information over time with the hope that some of these interventions will help them live a healthier life and get through their difficult moments. 

How has the safety net changed recently and how might it change going forward?

Generally it hasn’t changed in the last probably 50 years since the Great Society under Lyndon Johnson. My theory is that it has only changed at the margins. There have been two enormous events with respect to the American safety net. One is the New Deal under FDR and then the Great Society under Lyndon Johnson, where he created all sorts of new programs such as affordable housing programs, expansions, and SNAP benefits and things like that. 

For the most part, the safety net stayed the same. It’s only lately where people are beginning to think about, is this an efficient safety net? After indexing every program in the United States, I believe that the safety net is inefficient, with large cities hosting thousands of redundant non-profits. I think the safety net will see more consolidation among these non-profits as technology makes it easier. 

You’re already beginning to see that consolidation with mergers of different community-based organizations, different United Ways throughout the country. There was one within the last couple of years here in Austin between two of the neighboring United Ways. For those who don’t know, United Way is a great organization that works on collective impact by looking at the entire community and looking at the entire landscape of organizations that serve others. 

What I also think will change at this pivotal point in the future is that the federal government is experimenting with allowing social services to be paid for with Medicaid dollars. But the reality is that it’s still a theory, meaning that despite what vendors may tell you, there isn’t overwhelming evidence quite yet, at least through academic studies, that make the case that these interventions will drive down the cost of healthcare. There are so many variables that it’s hard to manage. It’s hard to study that and there’s not a ton of information.

My gut feeling is that allowing states to have more flexibility around what they spend their Medicaid dollars on will ultimately result in better health outcomes, but it’s going to take years to prove that. If we can prove that, then we as a society, or at least the states, will have the ability to decide what interventions are more relevant. For example, if a Texas Medicaid member is unhealthy and they can’t use their air conditioner because it’s broken or they can’t afford their electric bill, an intervention might make sense, if it’s medically necessary, to pay for that electric bill or that air conditioner repair with the dollars that came out of a Medicaid budget. That might be a different intervention in Maine, where transportation is a big issue, getting to the doctor is a challenge, and those Medicaid dollars could be used in Maine. 

I hope that with the change in administration, more flexibility can be given to the states to allow for them to design their own interventions with some flexibility of using Medicaid dollars to design these social drivers of health interventions that make a lot more sense at a local level. To allow local care coordinators to decide that they will help this family with the rides to the doctor or help with their electric bill based on everything that they see about the person. I’m also optimistic about the future that less regulation at the federal level of the Medicaid program, in this case, will lead to more innovation in the future. I feel like the states probably want that flexibility and are competent enough to administer innovative programs these days.

How are health systems using social determinants of health and what role do they play in addressing the needs that they might identify?

We work with a couple of hundred health systems nationwide. They have different requirements to look after the social needs of their patients. In some cases, those are driven by federal and state requirements. In some cases, those are driven by risk-sharing agreements with payers. Their goal is to make sure that the patient gets healthy and doesn’t consume unnecessary medical services.

Our customers integrate our platform into their system of record, whether it be Epic, Cerner, EClinicalWorks, or NextGen. We are integrated with hundreds of organizations so that they don’t have to do double data entry. We have the patient context when they click into our platform. We utilize SMART on FHIR integrations and some deeper API-based integrations. They want to be able to, within their medical record,  make a referral to one of the social service programs that we index and that we contract with. To be able to make those outbound referrals and also understand what happened after the person received those benefits. That allows them to have a whole picture of what’s going on with the person from right within their electronic health record. 

Different hospitals are doing different things. For example, Boston Medical Center has been innovative over the last five years that we have worked together by implementing all sorts of initiatives. Some are going as far as putting food pantries into their systems. Others are building community gardens. Others are contracting with non-profits to provide additional services for their patients. We’re the software platform that integrates with that and helps make those types of interventions happen.

Do the social services organizations receive the SDOH information in a standardized format and then have it integrated with the systems that they use?

We have indexed about 550,000 distinct program locations in the United States. These are all physical locations that provide social services to people in need. Probably the most common system of record is still on paper. Second to that is Excel spreadsheets or Google spreadsheets. 

There’s a long tail of proper case management systems that non-profits use to run their organization. One of the more popular ones is Salesforce. They have a program where they’ll provide up to nine licenses to non-profits that sign up for it. We’re building integrations on that side as well. We have built several integrations, but the critical mass is still in spreadsheets and on paper for tracking that information.

There remains an enormous opportunity to educate these community-based organizations and bring them onto our platform. We will build integrations with these non-profit systems of record, but when they don’t have one and they haven’t made that investment, we provide a free platform that they can use. We’ve done that ever since the beginning of our business, so we have been able to recruit many to come over and use our platform. 

It’s a big investment area for us going forward. In fact, just this spring, we acquired a company called Kiip. It’s a case management system that is designed for these community-based organizations to be their system of record. We have since launched in the fall a fully integrated version of Kiip that utilizes Findhelp’s network through our APIs to be able to use the Kiip case management solution, make those searches to find services, and make those outbound electronic referrals that hit the Findhelp network. The information is then stored within Kiip. 

We offer this for free, with an optional premium version for non-profits. But because there wasn’t a critical mass case management solution, that was an opportunity for us to create one and to put that out there in the world. We also see this as something that isn’t exclusive to the Findhelp network. If there are other networks that exchange electronic referrals for the purposes of social determinants of health, we think the Kiip solution can be utilized to recognize referrals in other networks.

In the long run, I see this going like the cell phone networks, meaning that you can use your Android phone to connect to a different network if you want to. The same thing should be happening in our space to eliminate the need for one monolith. We can lead by example to provide a system of record to these non-profits and then allow them to add as many networks as they would like so that they can see electronic referrals in one consolidated location. 

The challenge is that we have to find the motivation of the community-based organization. Why should they close the loop on referrals? Some might say that it would help the hospital or it would help the health plan in their community, but that motivation just isn’t enough. It takes good software design to build the closing of the loop into the workflow for reasons that the non-profits want themselves. 

We have a lead user experience designer named Phil Robinson, a great member of the team, who focuses on understanding the motivations of these non-profits. A big part of what they’re motivated by is having good, clean records of what’s happening. Building the loop closure into that workflow so that they have accurate reports that they can use reports for fundraising, for running their operation, is a much better motivator for the non-profits. That’s where we see a huge opportunity, not only in the short term, but in the long term, to have somebody on the other end of that referral closing the loop on that for their own reasons. We expect to see even more growth in that area. 

Who benefits from that? The hospitals benefit from that because they will see a higher closed loop closure rate. They will get information that would allow them to establish better interventions in the long run. If they see that a community-based organization is active in their city, they might want to work together and maybe even reimburse that non-profit for some of the work that they’re doing because it benefits their patients in the long run.

Findhelp is trying to solve the information problem that exists. A big part of that is bubbling up that information so that smarter people than I can do something with it. We believe the key lies in providing good user experiences, Not only at the hospital and plan level, but also at the non-profit level. 

Will AI affect what you do or how you do it?

I’m definitely not an expert on the subject, but I think that the number one benefit that AI can have, at least in our world, is to improve the workflow of the user.

I’ll give you a quick example. Our customers are continually telling us about changes in their community that they discover while using our software. They might discover that a program that serves people who are looking for affordable housing has changed their hours of operation. We built something called the Program Manager that allows our customers to make those updates directly. We have a curation team in-house here in Austin and we work together on those situations. But what we’re building into that application is the ability to proactively suggest those changes and to correct errors in real time.

We use a taxonomy called the Open Eligibility taxonomy. That’s a free and open source version that we built and put out there in the world. A user may not understand the tags as well as some of our employees might understand the tags, so we can build AI models that look at the descriptions of the programs and say, I think this tag is probably more accurate, would you like to select it?

Those are the tiny things around the edges that are going to make for a better workflow in the long run, which makes for a better data set in the long run. That will be an important part of decreasing the amount of time that our customers use to interact with our systems.

Another area is using AI models to help our customers understand which patients might need an earlier intervention. We have a lot of data about a patient, coupled with data that’s in eligibility files with the payers and other systems. When you have a large number of patients that you’ve made outbound referrals for, we learn a little bit of information about what occurred with those referrals. If I’m the case manager sitting in front of my computer the next day, sometimes it can be overwhelming. Building features that allow you to see that Hannah could probably use a phone call right now. That’s where we see our organization using AI to increase or improve on the user experience of our users. There’s probably many more that are there. 

As we uncover the use of AI for looking at large data sets, I’m interested in that in the long run.  We just crossed 50 million users on Findhelp, and over 20 million of those users were within the last year. We want to be able to study that data with the help of some of these models to understand trends that may be happening in a more regional level at the community. It would be more macro, but that’s another area where we think there’s a lot of possibility. The challenge is deciding which ones to focus on first. Right now we are focused on making our workflow better and better by using some of these technologies in the future.

What will affect company’s strategy over the next few years?

The number one thing that affects our strategy is that we are trying to build a new safety net, starting from scratch. When Social Security was first enacted, the business problem that came across was there was not a unique identifier for identifying every American. Hence, the Social Security number came out. If you fast forward to unemployment insurance, it was hard to come up with a rate for unemployment insurance because there wasn’t a centralized way of storing people who were unemployed. 

Information problems have presented themselves throughout our history. That same information problem is happening today with respect to organizing the safety net. I was reading this book by Henry Seager called “Social Insurance: A Program of Social Reform.” He wrote, “It is impossible, with our present knowledge, to estimate the extent to which illness and death are preventable.”  That was written in 1910. What is pretty amazing is that because of the work of a lot of your readers, that’s no longer a true statement. Today, that information has been digitized. The information problem that prevented people from estimating the extent to which these illnesses are preventable has been solved. 

The biggest thing facing us going forward is, how do we do the same thing for the social services sector? Our contribution to the world will be that every American understands what their options are in their time of need, but also trying to ensure that as many non-profits as possible have the tools that they need to solve some of these problems. Just like we’ve solved the unique identifier issue with respect to Social Security, your readers have solved the electronic medical records. Making them electronic in the first place was an amazing feat. We would like to do the same thing for the social services world.

HIStalk Interviews Frank Harvey, CEO, Surescripts

Frank Harvey, RPh, MBA is CEO of Surescripts.

Tell me about yourself and the company.

I am privileged to have been in healthcare for over 40 years now. Initially as a practicing pharmacist, then in the life sciences industry with Eli Lilly and Hoffman-La Roche, and with a number of health technology companies servicing healthcare. I was CEO of Liberty Medical, which was the largest diabetic testing supply company in the country. I had the privilege of being CEO of a company called Mirixa, which is a medication therapy management technology company. I ran my own venture fund for about three years. Now I have the privilege of being on the Surescripts team as CEO.

Surescripts is a trusted health information sharing company. We support the movement of clinical data between clinicians, physicians, nurses, and pharmacists across the nation. We are the e-prescribing backbone for the country. Our 24 billion transactions that we do in the movement of clinical data across our networks each year empowers clinicians to not only e-prescribe, but to get price transparency information and to make sure that they are making the right choice for each patient. The medication history information that goes across our network empowers physicians to make the right medication choices based on what a patient’s history has been historically. We are a mission-driven company focused on improving healthcare, reducing the cost of care, and improving patient safety.

How do you see the big picture of interoperability and the business and clinical opportunities that it might create?

The most important thing about clinical interoperability is how it’s going to empower the clinicians to be even more effective at treating patients. It gives them the full clinical history, the important information for what they’re working with the patient on. Last year we had 24 billion transactions across our database from virtually every physician, every pharmacy, every health system, and every EHR we are connected to, across all of healthcare working together. 

TEFCA, the Trusted Exchange Framework and Common Agreement, and the QHINs, the Qualified Health Information Networks, will make data more readily available for the clinicians to make sure they get a complete clinical record. Historically, patients move from health plan to health plan, and sometimes from physician to physician that may be on different EHRs. Many times the clinician didn’t have a complete clinical history to make the right choices. QHINs will help solve that issue and make it transparent to the treating pharmacist, physician, nurse, or physician’s assistant, giving them right clinical information that they need to make more appropriate clinical decisions for patients.

How does the use of an e-prescribing network empower patients compared to paper prescriptions?

The most effective prescription is the one that the patient will actually pick up and take. Many times historically, patients weren’t aware of the price of medication. A physician would write a prescription, the patient would take it into the pharmacy, and then it would be like, well, I can’t afford that. Pharmacists would have to take time to call back the physician’s office, or the patient would just abandon the prescription.

Real-time prescription benefit provides a number of things around transparency. It’s meant to be when the physician is right there writing the script with the patient. They can see not only the prescription that they are thinking of writing, but also the therapeutic alternatives. What medications could be used in place of that? What’s the cost of that prescription based on the patient’s benefit? What’s the cost of that prescription at different locations? Mail order versus retail versus preferred retail?  All of those factors are now at the physician’s fingertips. 

We have over 800,000 physicians in the US utilizing a real-time prescription benefit product. Having all of that information at their fingertips helps them make the right choice for the patient, because it’s not just a clinical decision. If the patient can’t afford the medication, there may be other medications that will be more therapeutically appropriate because the patient can actually afford to pick it up and take it.

What are the technology approaches for improving the efficiency of processing prior authorizations?

The concept around prior authorization was smart. It was to ensure that patients were taking the right medications and the right sequence to make sure they received the best treatments. Often it’s not just the most expensive medication that would be the best, but the most appropriate. There may be step therapy that a patient could go through. Since historically physicians didn’t always have complete medical records for patients, that was one additional way to help inform the treatment decisions.

What has happened with prior authorization is that it is much too cumbersome for the physicians and their offices and the pharmacies that have to delay things and step back. Most importantly, it is much too cumbersome and delays treatment for the patient. It’s really the patients that are being hurt by the delays that take place in the prior authorization process.

Fortunately, we are at the forefront of working on new technology to help solve a number of those issues. We’ve just published our pilot results with Optum and Cleveland Clinic Fairview, looking at what we’re calling no-touch prior authorization. It’s our ability to end the workflow for the physician to get that prior authorization approved while they are prescribing the medication. Because we are connected to every EHR, we have clinical history on these patients. We can reach out across those clinical records in a matter of seconds, pull that record back, and complete that prior authorization so that it goes through smoothly. The medication isn’t delayed for a couple of days because the pharmacy hasn’t received authorization.

New technology and our new advances are helping patients, most importantly, but also cutting down on clinician and staff burnout that is caused by all of this faxing, calling, and delaying work.

Are payers embracing the gold card type program, where prescribers who have history of responsible prescribing aren’t required to go through the same level of prior authorization scrutiny?

The gold card program is helpful for physicians who have proven that they always go through the right step therapy and put the appropriate medications first for their patients. It’s important since all that information is not always available to a physician and the cost of medications is extremely important to the overall system as well. It isn’t always the most expensive medication that is the most appropriate. Prior authorization was trying to solve some of the issues around that and to try to keep healthcare costs at a minimum while still providing good clinical care to patients.

Our real-time prescription benefit product shows what a patient’s coverage is, what their benefit is, and whether a product is covered or not. But in addition, our newest advances in prior authorization are showing those and filling out those electronic forms for physicians in a matter of 30 to 35 seconds in the prescribing process. That’s really freeing up a lot of time. It’s taking a lot of the burden off of the physicians having to do a lot of that work.

Physician offices have a number of people who are working on prior authorizations. Then there’s a whole host of people at the health plans and PBMs who are taking those calls and working through them as well. Creating efficiency through our new technology will help remove a lot of that provider burnout and get patients on therapy quicker.

How do you build a business plan around the possibility of incorporating AI into products and strategy?

We’re just starting to scratch the surface on the benefit that AI is going to be. Surescripts technology has been built around machine learning from the beginning of the company. Generative AI carries some surprises, and caution is needed because it can have hallucinations and make stuff up if it doesn’t have the right answer. Because of that, whenever you have generative AI involved in a recommendation or decision, it has to have human intervention in there as well. It has to be checked. You have to make sure that what that generative AI is coming back with is right. You have to have human intervention in that. I don’t see that going away anytime soon.

Where I think AI generative AI is going to have the most impact is with administrative functions, prior authorization and others, where it can help pull in that information from the notes fields and from other areas to show what a patient has been on. But again, always needing that human intervention to confirm what the generative AI is coming back with.

Does your network offer new opportunities to add value or improve care?

A good network takes a long time to build. We’ve been at it now for over 20 years. The Surescripts Network Alliance is all of our partner companies across that multi-sided network working together on these hard systemic problems. These problems that we are focused on are systemic across all of healthcare. When you find a solution or come up with a solution, it helps everyone in the process, including the patient. As we continue to build out the networks, QHINs are a great example of additional networks being added to the framework. Being attached to every prescribing physician, pharmacy, health system, and EHR lets us see the value that the network can bring to the patient.

What are the technology implications of the Drug Enforcement Administration’s recent warning about the security of e-prescribing systems?

It’s a multi-pronged effort. Bad actors are getting more and more sophisticated. They are looking for new ways every day, and you have to be vigilant. 

At Surescripts, it starts with the rigorous standards that it takes to become a part of the Surescripts network. We at times have heard complaints from some new health technology companies that are trying to get on our network. But once they understand that we’re responsible for protecting the security of this across the nation, and so it’s not easy to become a part of the Surescripts Network Alliance. But when you do, you’re sure that it’s at a level of security that is beyond reproach.

It’s also the standards that you put in place. At Surescripts, we follow the National Institute of Standards and Technology, NIST, Identification Assurance Level 2. This is a higher level of security than is required in general. Every health technology company and EHR on the Surescripts network has to comply with that higher standard.

We work hand in hand every week with the DEA or the FBI as they are investigating cases of prescriber fraud. Physician identities will be stolen and you’ll have somebody sending out 1,000 scripts in a matter of minutes. Our systems catch those sort of things. The tough ones are the onesies and twosies that don’t rise to the top. That’s why we have to continue to be diligent working with the pharmacy operating systems, pharmacies, the health technology vendors, and our systems to make sure that we are staying on top of that. 

There will always be bad actors out there and they will always be looking for new ways. The DEA is wise to recommend that you stay vigilant around that. We require our health technology vendor partners to be vigilant and to have a standard of what’s required of their prescribers on the network. We just announced a new partnership with Clear, which will add another level of ID proofing.

As a pharmacist, how has the profession evolved and how might it change going forward?

I graduated 40 years ago. I’m a  Bachelor of Science pharmacist. We had a couple of PharmDs when I was going through school, but most of them were going into hospital practice. Now every pharmacist is graduating with a PharmD. The rigor of their clinical training is beyond reproach. They are critical members of the overall healthcare team.

The other thing that is driving the need for pharmacists to become even more active is a lack of primary care providers. We know there’s going to be a shortage of about 130,000 primary care providers by 2030. Pharmacists are well equipped from a knowledge standpoint to step into that gap to be a part of that collaborative care team to help make life better for patients. That is the most significant advance I’ve seen in those 40 years, the role that pharmacists are playing as a critical part of that primary care team.

If you look three to five years in the future, I think that at most pharmacies, you’ll see pharmacists spending 70 to 80% of their time interacting with patients in that clinical interaction. Not just immunizations, but working with patients on insulin dose adjustments or with patients who have hypertension or CHF in those in-between visits when they would normally go to a primary care provider in the past where their primary care provider may now not be available.

The role of the pharmacist is going to continue to expand as the legislation expands the pharmacist’s authority. During the pandemic, the federal government stepped in with the PREP Act that allowed pharmacists to give immunizations and to be more active in a number of ways. The federal government just extended that I believe to 2029, maintaining the authority of the pharmacist to do those other clinical functions. We need to continue state by state, because it is a state-mandated or state-allowed monitoring of the practice of pharmacy and medicine. We need to have the states continue to authorize pharmacists to work across the full scope of their training, because they are critical to the care team. The physicians we speak with say they are so much more effective when there’s this collaborative care arrangement with the physicians and the pharmacist working together for what’s best for the patient.

Private equity firm TPG recently took a majority position in the company. How does that change your business?

I can’t overstate how important that is to us. We started about two years ago working with our board to say, what are the opportunities that Surescripts needs to focus on in the future? Those opportunities continue to focus on things like prior authorization, extending clinical practice for pharmacy and empowering them with the right information, and increased interoperability. All those things take a lot of financial wherewithal.

We met with almost 100 equity companies over the last two years, narrowing it down to what we believe is the finest healthcare technology-focused private equity company in the world. TPG is really there with us, enabling us, providing the financial backing that we will need to continue to not only build organically, but to look at the right acquisitions that make sense for Surescripts to add to our technology in areas that we focus.

What are complementary areas that you might consider?

We are focused on things that can help take out that administrative burden for patients, for physicians, and to help patients. Prior authorization. Thirty percent of the pharmaceutical spend goes through the medical benefit, which is another area that’s important. Also, the data and data insights as we look at 24 billion transactions a year. There’s so much value that can help with patient care in that, in the midst of all those data elements, helping us refine and look at the best recommendations that we can help make to providers on the patient’s behalf based on all the clinical data that we have. All of those are areas that TPG is excited about. 

One of the things we like best about them is that we share a similar culture. We know that we’ll do very well as a company by doing good — doing good for patients, doing good for providers. In one of the first meetings we had with TPG, they echoed that we’ll do well by doing good, and the financials of the company will take care of themselves. We share that same vision of healthcare and the impact that we can have in healthcare.

What does the health tech investment climate look like?

The last 18 months has been a little slower on technology investment. I think you will see that start to ramp back up again. The impact of AI in the short term is going to be less than people are stating, but in the long term, I think people are underestimating AI’s real impact on healthcare and on multiple industries. It will help us continue to reduce the cost of healthcare. The climate is favorable for that investment.

Healthcare is such a large part of our overall economy. Healthcare is still broken in a number of areas, and it needs fixing. We don’t need just little point solutions, because many times a point solution solves one problem, but it can create a problem upstream and downstream from that point solution. We need larger, systemic solutions that can solve across the whole healthcare spectrum. That’s what we’re focused on as a company.

What are your priorities over the next few years?

The most important priority is what it has been historically, which is to continue to have the best employees that you can have. I am so proud of our team, the quality of the individuals on our team, and the caring nature that our culture has. We’re really focused on what’s best for the patients and the providers, and that comes through in the quality of the work. Continuing to have the best members of the Surescripts family will always be job one for us. Then it’s continuing to partner across the Surescripts Network Alliance, which is how we will go further faster in working with all of our partners in healthcare to solve these big systemic issues.

A lot of the parts of healthcare are still broken. We need to work as a collaborative across all the healthcare technology companies, the EHRs, the PBMs, the pharmacies, the physician groups, and the health systems. Working on these problems together, we can help fix that healthcare system, take a lot of cost out of that healthcare system, and do what’s best for the patients.

HIStalk Interviews Bob Katter, President, First Databank

Bob Katter, MBA is president of First Databank.

Tell me about yourself and the company.

I’ve spent my entire career in healthcare, primarily health IT and a little bit of health services. Before joining First Databank about 15 years ago, I was with RelayHealth and then McKesson for several years. At First Databank, I’ve previously headed up the commercial and consumer-facing functions, and then at the start of 2020, right in time for the pandemic, I took on the role of president.

First Databank, which I think is referred to by most in the industry as FDB, is one of those companies that few people outside of the industry or even inside it have heard of. We play an important role. Many healthcare delivery organizations, probably a majority, count on us to provide timely and accurate medication information. We support a whole range of clinical, administrative, and financial workflows. We aren’t an application, per se. We’re the content that supports it. That can be an EHR system, a pharmacy management system, a claims processing system, and other types of systems.

We recently expanded beyond that core business to get into the e-prescribing network business with FDB Vela. It’s different than our core content business, but also related, in the sense that a lot of the customers, the people who use the network, are the same people who use our medication content. We think that our expertise with the content gives us a unique and special way to do that e-prescribing network.

How has medication decision support changed in terms of personalization and making the information actionable to the correct person? 

You’re absolutely correct. That is our core business, and in many ways, is the most important thing that we do. It is changing a lot, and I think it’s about to change a lot more because of the advances in technology and generative AI. 

Everyone is probably saying something similar, but even prior to these recent advances in AI, just through FHIR and those types of things, we’re seeing a much greater ability to pull information from whatever clinical system in which our content is being used to make the content or the decision support that we provide more patient specific and more actionable. The clinician not only gets the patient-specific information, but is in a good position to act on it right then. A clinician should consider a number of patient-specific factors when ordering a med, for instance. Those include demographic factors, which we’ve also always had, but also clinical factors such as diagnoses, allergies, other meds the patient is on, lab values, risk scores, and increasingly, a patient’s genetic profile.

The technology is evolving to the point where we can access this information in real time and provide that succinct kind of impact statement. “Here’s what that means for this patient in this order,” and even give some sense to the clinician not just as a safety check, but potentially a more actionable, “Here’s what you ought to do.” We are doing that in the hospital setting. We are also doing that in the pharmacy setting. We’ve rolled out a program with CVS that we’re excited about. They don’t call that decision support, they call it DUR, drug utilization review, but it’s a pretty similar process. It is focused on very patient-specific information and focuses on the actions the clinician should take as a result of this information.

How might that process be changed with generative AI, which could help make sense of the information in context or tie into external references?

As you can imagine, that is question that my senior team and I are spending a lot of time on. In terms of building on what I was talking about a minute ago about patient-specific decision support, one thing that these large language models can do better than any other technology that we have worked so far is to take unstructured data and do a reasonable job of structuring it. Through standards, there are ways to pull structured data out of an EHR and put structured data back into an EHR. We are doing that with several EHR partners. But a lot of the data inside a chart, including meaningful and useful data, is in text form, in an unstructured form. The LLMs provide a lot of promise in terms of being able to pull data out. We are working on that right now to support several clinical and administrative workflows.

Something else that this type of technology can do is in the area of so called real-world evidence that people have been talking about. You can essentially ask the technology, what have clinicians done for thousands of other patients that look very similar in terms of clinical context to this patient? I don’t think that necessarily provides a definitive answer, but it’s another perspective that you can surface in front of the clinician that would be useful advice when combined with the so-called traditional evidence that FDB and companies like us have based our content on to this point.

In our AI testing, it’s very good, but it’s not at the near-perfect or perfect standard that I think our industry will require for clinical decision support. There remains a role for experts to guide and manage the technology. In our business, 99% is not nearly good enough. We’re talking about a 99.9999% standard. Based on what we’ve seen, to get to that level of accuracy and consistency will require expert humans along with it. That said, there’s no doubt the technology is very powerful and is continuing to advance. For pulling things that are unstructured and structuring them, as well as offering that real-world evidence component, we think the technology is going to become very useful.

What opportunities does a prescribing network such as Vela provide in connecting not just providers, but other types of participants, such payers?

In terms of other types of participants, the current network and Vela support all of the NCPDP standards. The currently available networks already support connectivity between the prescribers who use an EHR system; the payers, if you consider the payers to be PBMs in this case; as well as the pharmacies. But one constituent that is left out of that equation is the patient themselves. We think that is important. 

Vela supports a workflow where the patient doesn’t receive an actual prescription that they can do anything with other than forward it. Patient choice becomes an important component, and the networks should support that. That has been done in the past by having a patient-facing app mimic a pharmacy, but we don’t think that’s the right workflow because it removes subsequent pharmacy-to-physician communication that the standards support. You need to have a different role. Thankfully, NCPDP has worked with us and there is a standard that supports that. You need to have a different role for the patient, and that’s an important constituency.

When you get into specialty drugs, you can use the prescribing network for all the standard things. But when you get to prior authorization, specialty enrollment, and patient financial responsibility, those are all separate transactions that the provider’s office has to manage separately. We think there’s a real opportunity to pull all of that into one unified system. The provider would write the prescription in the EHR system. Then, all of the information that you need to support those subsequent workflows — whether that’s a real-time patient benefit request, a prior authorization request, or specialty enrollment request – can be done with data or content from the EHR. That’s where you get back into pulling things out of the EHR that are unstructured and the promise that AI has for that as opposed to just structured information. There’s a lot of opportunity to innovate in that area.

We’re up to somewhere around 10 or so partners that have consumer-facing applications. Something that the patient can use, typically on their phone, to manage their prescriptions. Our network supports the standard by which that application can essentially receive a copy of that prescription, and then the patient has the ability — depending on which application it is — to do all sorts of things that include choosing a pharmacy from the pharmacy network and decide where they want that prescription sent.

It’s also an excellent opportunity to surface other things. You mentioned real-time pharmacy benefit. That, along with a coupon from a company like GoodRx, allows the patient to make intelligent decisions based on their financial responsibility. They can seek to fill the prescription at a pharmacy where they can afford their co-pay or co-insurance, for instance. We also think that here’s an ability, once the patient is in that workflow, to provide information around adherence and things that are going to help that patient fill that drug initially and stay on that drug subsequently. We’re not an application company per se, but we will support any kind of NCPDP-compliant application that can manage and forward prescriptions.

How extensive is the use of precision medicine and genomics in in ordering drug therapy?

There are several hundred drugs that have good, published clinical evidence to support it. A lot of those are in the central nervous system area, mental health drugs, pain drugs. There are certain therapeutic categories where there tends to be more evidence. It’s very specific, such as if you have this particular genetic variant, you’re going to metabolize this particular drug differently, so you need to change the dosing. Sometimes it’s an absolute contraindication given a genetic variant, where we would advise the clinician to prescribe a different drug.

A couple of years ago, I would have said that this is something that we love talking about, but we’re a little out in front. It’s very much going mainstream now. We’re getting both public and private hospitals adopting it, particularly those that use Epic and Meditech EHRs. We are finally starting to see this come into clinical practice in a major way.

What is the status of recording and using medical device information?

For several years, we have published a database called Prizm. It’s a comprehensive database of Class I, Class II, and Class II medical devices. It’s fairly different than medications, and maybe even we didn’t understand how different it was initially. Medical devices are not managed in the same way as drugs. There isn’t that definitive set of content or set of therapeutic categories anywhere near to the same extent as drugs. We are continuing to work with health systems and starting to see traction.

In terms of the use cases, there are almost too many to list, but I guess I could just throw out a couple of pretty obvious ones. One is inventory management. If you truly understand which devices are in which categories, even to the point where you could substitute this particular device for this other device if supply is short or the price goes way up, then hospital systems should be able to manage their inventories much better and probably save a lot of money in the meantime.

There’s also a patient safety aspect to this. Somebody in a hospital told me a couple of years ago, and I hope it’s not completely true, that, “We probably have a better idea of what cans of food are on our grocery store shelves nationwide right now than we do of which devices we’ve implanted in which people.” This idea that we’re putting implantable devices in people and we’re not able to completely keep track of which patient has which device or which generation device it is, affects decision support as well as recalls. I may be being a little too critical of how that’s managed, but I think that with a more standardized content source, the industry can do a much better job.

What consumer-facing use cases do you see for your products?

There’s a big gap in what patients are prescribed. Maybe a Medicare patient has a number of meds and doesn’t understand why they’re taking them, how to take them in cases where it’s more complex than just swallowing a pill, or which meds they should take at different times. We provide specific information beyond the long, industry-approved monograph that covers everything. What are the most salient points that the patient needs to know?

There’s also a need to provide patient information at an appropriate reading grade level, which might involve using pictures or so-called pictograms that are more universal and easier for people to understand. Also making the information available in multiple languages. We have an incredible number of people living in the United States for whom English is not their first language. They might not understand something as complicated as medications in English. This is obviously another area where AI will provide tremendous assistance.

What are the company’s priorities over the next few years?

I’ve been spending a lot of time in the past year or 18 months thinking about that, given how fast things are changing. With the ongoing advancement and adoption of AI technology, clinical practice is going to change pretty dramatically. The amount of information that can be made available to clinicians to aid in their decision-making process will be immense, even relative to what it is today.

The priority for our company is to say,  how do we play?  If more hospitals are using ambient AI technology in patient encounters for charting, that might  kick off a different workflow for how decision support works. We’re going to want to make sure that our information is made available in that setting. Maybe the clinician won’t be typing in the order and managing it the way they traditionally have. Maybe it will be more of a verbal process. A huge priority for us is to understand how those clinician workflows will change and how we can participate and remain valuable to the clinician in that process.

We will determine how we can leverage AI and real-world evidence in new ways. Not to stop doing what we do now in terms of the traditional evidence, but combine it with the larger amount of content and data that we can get using real-world evidence and how that combination of things can be more powerful. 

HIStalk Interviews Thomas Charlton, CEO, Goliath Technologies

Thomas Charlton is chairman and CEO of Goliath Technologies.

Tell me about yourself and the company.

We offer software that plays a critical role in ensuring that clinicians have seamless access to clinical applications so that they can focus on delivering a high quality of care. As a company, our mission is to work with health IT and focus on the areas of availability, speed, and reliability of EHR systems, most commonly Epic, the Oracle Health EHR that was formerly Cerner Millennium, and Meditech.

How would you contrast  the use of end user experience monitoring and troubleshooting systems to the traditional model of waiting for users to open trouble tickets?

Users will assign blame when it comes to speed and reliability to whatever they see on the screen. If it’s the EHR, they will say Oracle Health is slow, or Epic is slow, or Meditech is slow. That reflects on the IT organization.

What we’ve found in health IT, which is unique relative to enterprise, is that clinicians are very busy. It’s the unreported issues that are the real problem. Clinicians can take their caseloads to other hospitals where they have privileges. There’s a significant amount of data around burnout.

Through our partnerships with Oracle Health, Meditech, and Epic, we give health IT executives, staff members, and clinical executives the ability to understand if clinicians are having experience issues or usability issues. Who is having those issues? How often do they occur and how long do they last? What is the cause? That is incredibly important, because if you are dealing in the realm of unreported issues, there’s a baseline of consistent dissatisfaction. We provide empirical data so that you don’t have to rely on feedback from clinicians or other users of the technology.

What changes in the first several months after a health system implements your system?

Our technology’s ease of use and price profile gives us the ability to scale to some of the largest health systems. Some of our current clients are CommonSpirit, Ascension, Oracle Health themselves, and small regional health systems such as Southwest General and Maine Health. If you talk to of those, they will say that it’s being able to quickly identify issues that affect clinicians. We do it with data. It’s easier to identify and fix problems when the root cause is identified.

They will also say that the clinician experience is substantially improved, because we’re not just solving reported issues more quickly, but providing visibility into unreported issues. They would cite a reduction in reported issues, a substantial reduction in the mean time to remediation, and immediate assessment of the criticality of issues.

Imagine that you are receiving a large number of complaints from the 10,000 users in your health system. That makes it seem as though there are problems everywhere. On demand, you can run a quick report through our technology so that you can frame up where the problems are occurring, who is having those issues, and very likely identify the root cause.

Probably one more thing to note is the vastly improved communication between health IT and the clinical sides of the health system. Conducting surveys is the traditional method that is used to gauge clinician and user satisfaction with EHR applications. But surveys are not timely. They don’t provide actionable data. They are subjective. We bring empirical data into that subjective conversation. Both sides of the organization, clinical and IT, are looking at a common set of facts and figures around end user experience.

How are user experience problems spread over application problems, infrastructure, connectivity, and third-party software?

If you look at KLAS’s House of Success, a number of factors support a good EHR experience for a clinician or user. One of the factors is application processes. How many clicks does it take to admit a patient or download a lab report? We don’t deal with that. We focus on availability, speed, and reliability.

In that situation with those three components, it is a complex mesh of technologies. If you think of just the simple logon sequence, are they using Citrix or VMware Horizon to grant secure access to these applications? Are they hosted, primarily like Oracle Health, or on-premise like Epic and Meditech, although that’s changing because they both have cloud offerings now.

You have the user. You have whatever their particular device is. You have where they’re connecting from, the service provider, the network, and then back into the back-end systems that support the application. We cover all of those variables. 

We’ve had years of experience and many man-years of development to be able to automatically correlate data from various sources, look at the end user experience specifically, and determine that of all of those factors, which are the most likely root cause of the issue. We use a combination of AI-enhanced data, automation, and embedded intelligence to be able to determine which of those. They are all silos in an IT organization – database, application, end-user device, server, et cetera. We use data to determine which of those silos, one or more, is the root cause of the various issues.

What is the cultural change of an organization that moves from a complaint-based system of clinician satisfaction to a fact-based, measurable data approach?

It’s phenomenal. If you can’t frame up the problem, if you don’t know who is having problems, the frequency of those problems, the duration of those problems, and why they occur, it is literally impossible to take any action.

Clinical executives would hear complaints from their clinicians. Health IT wants to provide a good clinician experience for all the reasons that we’ve talked about, including the impact on patient care. But if you don’t have data, how do you determine where the root cause is? You can’t frame up whether there is a critical issue or not. 

We find from the health systems that use our technology that communication between the clinical side of the house and IT is vastly improved. You have engineers on one side and scientist clinicians on the other side, and now they are able to look at data. Data is friendly. It may not be welcome data, but it is objective. We are bringing actionable data into what is typically a subjective dialogue. They can look at our data as a team and put together a productive plan to resolve issues permanently.

How is the experience of clinicians affected by off-campus locations, remote work, and the use of mobile devices?

We have a great example from the University of Kansas Health System. A clinician is working in the hospital. They have great system performance during the day. They go home at 6:00 or 7:00 at night and their performance using Epic is fine. Around 11:00, a call comes in. The clinician is in their bedroom, they need to access Epic, and now the performance is slow. The performance should not be slower because there are fewer people using the systems at that time of night, yet there is the reality of that.

The IT folks can run a report in our product and show the varying degrees of connectivity that happen. They can sit with the physician and say, if you look at your entire day over the last 30 days, the problems that you are having are always at this time at night. Where are you at those times? They were able to determine, oddly enough, that it was because there was a lack of connectivity on the other side of the physician’s house. They were too far away from their router in their home.

This is what changes the paradigm. We are able to deliver both to health IT as well as to clinical executives on demand that visibility into the clinician’s experience with their EHR application as it relates to availability, speed, and reliability. You no longer have to be in a reactive mode. You can be proactive and understand where issues might be occurring so that they can be preemptively solved. It really changes the dynamic and improves the satisfaction of the clinicians. It’s not uncommon for health IT executives to say that we’ve helped improve the reputation of IT.

What opportunities are you seeing to be able to use AI to enhance your products?

We’ve had AI in our product now for about eight months, so this is Version 1. AI makes fault isolation and resolution easier. It reduces the mean time to resolution.

It also democratizes deep IT knowledge. A ticket or complaint comes in, it goes to a help desk, and then it’s escalated. When it’s escalated to Level 2 or Level 3, these are very serious issues. They are causing clinician experience issues, and very likely have patient impact. Those very experienced IT technicians have to spend a tremendous amount of time without our technology trying to understand where the root cause is. 

We use a combination of AI-enhanced data to show them where the issue is. We also offer suggestions about how to resolve the issue.That has given our organizations the ability to push the resolution of those issues down to lower levels.

You may have a clinician who is interfacing with a patient and is having speed and reliability issues. Every one of those help desk escalation points is a delay to reaching a solution. Our technology allows resolving issues at Level 1 support, as opposed to being escalated to Level 3, where it’s put in a the working queue of an experienced IT engineer and can take quite a bit of time to resolve the issue. By pushing resolution down to lower levels, we are able to reduce the mean time to resolution, which impacts clinician satisfaction and ultimately delivers a higher quality of patient care.  It allows the clinician to focus on patient care and not technology enablement.

What are the key parts of the company’s healthcare strategy over the next few years?

We’re going to add more and more enhancements that give our health IT organizations the ability to resolve issues more quickly and be able to prove the root cause so that permanent fix actions can be put in place. Reducing the mean time to remediation and providing empirical data so that the quality of the clinician experience with Cerner, Epic, or Meditech can be improved demonstrably over time.

When looking at clinician EHR satisfaction. speed and reliability are the easiest things to change. They have the highest impact on clinician frustration. It’s easier to identify where these issues are. The fixes are quicker than training, education, and application changes. They impact physicians greatly, because when they are experiencing speed and reliability issues when they are in a environment with a patient, it’s visible to the patient and therefore the most frustrating to them personally.

HIStalk Interviews Lauren Patrick, CEO, Healthmonix

Lauren Patrick is president and CEO of Healthmonix.

Tell me about yourself and the company.

I am an IT engineer kind of person by training. I spent about 15 years working for consulting companies such as Capgemini and E&Y. I founded Healthmonix when I moved to Philadelphia about 15 years ago and wanted to do something more meaningful than selling tickets on the internet or compiling part lists for engineering firms.

Healthmonix is a healthcare analytics company that primarily focuses on quality metrics, with the MIPS and MSSP programs in particular. We got our start developing quality measures before everybody came to know what they were. I started working with the University of Pennsylvania to put together some CME programs. To figure out where the gaps in need were, we started using the Epic system to figure out what physicians knew and maybe what they didn’t know, then worked to provide performance improvement.

We work on quality metrics and now cost metrics as well, then help providers improve in those areas.

How do practices work and think differently in a value-based care model?

Rather than looking at fee-for-service — where every time you provide a service to a beneficiary or a patient, you are figuring out how to bill for that – it is focused on how to best take care of that patient, how to best serve that patient’s needs, and how to understand what that patient wants from their care.

How do you support practices that may have a mix of value-based and fee-for-service, or that work with multiple value-based care programs?

We take in all of the data for all patients. For the Medicare quality reporting program in particular, you have to report on all of your patients. No matter who the payer is – self-pay, private, Medicaid, or Medicare — all of those patients have to be included in your quality metrics panel in order to report to Medicare and get the incentives or avoid penalties. We track what their insurance is and can partition that data. We can show you quality metrics of your Humana patients versus straight Medicare fee-for-service patients.

We’re bringing all that data in, putting it in a repository, and then saying, here are the quality metrics that Medicare really cares about. We can show you those metrics from that data. Because of the way that we’ve built the software, we can also take that data and show you quality metrics that perhaps apply to Humana. We can take that same repository of information and pull it out in all the different ways for different reporting that is required. That’s quite a challenge, but that’s part of the beauty of coming at it from a data-based perspective. We pull all that data in and then build those quality metrics to help these folks report out with as little burden as possible.

How do physician behavior and education fit in?

While payment drives a lot of the participation in our programs, I started out working with UPenn trying to figure out how we could help providers improve. At the heart of what I want to do personally is to make a difference and help these people improve. But sometimes doctors will see these quality metrics put up on a screen somewhere and they will say, “No, these are wrong.”

We say, OK, let’s drill into them. Let’s take a look. This is the quality metric. You agree that this should be the standard of care, right? Let’s look at how your patients are or are not adhering to that. From there, you have to softly get these physicians into it. We’ve taught our physicians that they are knowledgeable and are out there making day-to-day decisions. To say to them, “Maybe you need to do something different“ is really a little bit of a shock to their system. It’s a standard cycle where they don’t believe, then they accept it, and then they have to figure out how they can change.

Is it enough to provide convincing data, or does change require having people on the ground to nudge them?

It depends on the personality of the physician. It also depends on the metric. You have to make sure that the measures that you’re putting in front of them are meaningful and something that the doctors can buy into.

When we started, we were looking at A1Cs. Let’s get the A1Cs down under fill in the blank – some doctors feel that nine is appropriate, some feel that seven is appropriate. Figuring out what that metric is, getting everybody to agree to that metric, and then having them work towards that. If they feel like it’s the right quality measure, then they are much more willing to work towards it.

When we do this, we look at process measures, which would be like filling out a prior auth or making sure that you put the meds in the EHR or whatever. But it’s the outcome measures that we are all striving for. Let’s make sure that our patients’ diabetes is in control. Let’s make sure their blood pressure is in control. Let’s make sure that they can walk out of the emergency department healthy. Let’s make sure that the patient’s objectives, in terms of what they want, are being adhered to. If you put the right metrics in front of these docs, they are much more willing to buy in, but you read journal articles all the time about how doctors don’t like a lot of the metrics that are being imposed by some of these programs.

What challenges are involved with collecting data from multiple systems and then packaging it together so that it is reliable?

That’s probably one of the biggest challenges industry-wide. We work very hard to pull data out of a variety of systems. Part of the challenge that we have now is that we might be reporting for not just an individual practice, but for an accountable care organization, which is a group of doctors that have banded together to say, “We are going to take responsibility for making sure that Mrs. Jones is healthy.” We have to pull all the data from all of those various practices and put it into one dashboard. We have to say, these are the outcome measures for Mrs. Jones, and who is working on that?

It’s hard to pull that data together because some of it is in an Athena system, some is in an Epic system, and some is in a billing system. Bringing it all together is one of the biggest challenges. We don’t just bring in a file, dump it, and say we’re done. We work with providers to understand where they are putting the data. A lot of times one doctor will put it in one field and another doctor will put it in a different field, so we have to understand that we have to get it from both fields. We spend a lot of time on data integration.

Has 21st Century Cures and broader interoperability improved that, or will it in the future?

That’s the dream. Everybody keeps saying FHIR, bulk FHIR, and all the regs that have come out. But some of the EHRs are kicking and screaming. They don’t want to share their data. Some of them just don’t have it together. Some doctors don’t put the data in the right fields for a standardized mechanism for data integration to be effective.  

What progress has been made with accountable care organizations?

Everybody says that’s the brass ring. That’s what we’re striving for. But I heard somebody from Intermountain say that it’s a 30-year journey. We are all working towards figuring out how to do accountable care.

CMS was a little stifled by the pandemic for a few years and the growth of ACOs didn’t occur 2020 through 2023. We are hoping that we are back on track. We see more and more patients being involved in some sort of accountable care relationship. That’s good. That’s what we want. We want somebody to be in charge of that patient’s health and to be looking at the whole patient. What we at Healthmonix are trying to do is to bring all that data together so they can see the picture of the whole patient.

Does having information available from multiple systems create new opportunities?

Yes, absolutely, and not just with EHRs. Social determinants look at where the patient lives. What sort of life does that patient have in terms of a support system? Are they in a food desert? Are they getting the sort of social support that they need? Then, combining that in. As we move forward, we’re integrating more and more sources of data so that when that patient walks into that care facility, a provider can get a much better picture of what is going on with that patient.

How do providers use the social determinants screening? Do any of the quality measures have it built in?

To get physicians started with using them, the Medicare programs, the ACOs, are giving providers bonuses for tracking those metrics. We call that pay for reporting. Then as we go forward, they are starting to factor those into measures. A lot of the measures are what we call risk based, where we take in social determinants or other patient history and give the provider credit for the fact that it’s a harder patient to take care of.

Is MIPS the only program that looks at these measures?

MIPS is a CMS program. It adjusts the payment that providers get from Medicare for fee-for-service. If you don’t participate in MIPS, you’ll get a 9% penalty on every single claim that you turn in to Medicare the following year. That’s a big hit. If you turn the data in that we compile — if we turn the data in for you, essentially — and you do well, then you can get up to a 2% to 5% incentive on every bill that you put into CMS next year.

CMS drives a lot of it, but there’s a whole rulemaking process that we participate in. We will draw up some of the quality measures that are in the MIPS and CMS programs, and then CMS will decide if they think it’s a good thing or not. Once CMS adopts it, it funnels out to private payers because there’s a certain standard of care that you want to adhere to for patients. A lot of what we do is based on science.

How does the cost analytics part of MIPS work?

MIPS decided that part of the score that you get from Medicare is based on this cost component. CMS is looking at how much is it costing to take care of your patients for certain episodes of care. When you have a knee surgery, what is it really costing CMS in terms of all the claims that come in for that knee surgery? That includes X-rays, anesthesiologist, the surgery if you’re in an ambulatory surgery center, the post-acute care that happens for 30 days afterwards, and complications. We look at that as a whole to say that the total cost of that knee surgery was X. We look at everybody across the US and figure out what the average was. If you did better than the average, then we say, yay, you’re doing great, and we give you an incentive. If you’re doing worse, then CMS will ding you for that.

What factors will be most important for the company over the next few years?

Data integration is a huge one. Can they really work to build better data interoperability? Because that will help a great deal. But I still think that we are going to need to spend a lot of time on data integration.

The other thing is that CMS is by far the leader in terms of where we’re going in terms of value-based care. Looking at the programs that they put forth, it will be interesting now with Mr. Trump to see how much he supports or does not support the movement into value-based care. I didn’t see a lot of changes in the four years of his prior administration, but there will probably be some changes in the next four years since he feels like he’s got a little bit more of a mandate. Those sorts of things will impact where we go with this.

Everybody’s favorite term right now is artificial intelligence. We report data for 50,000 providers across the US. To do these cost metrics, we gather a lot of claims data from CMS as well. We have a pretty big repository of healthcare data. Now we are digging into that data to understand the correlation between patients with great outcomes, both in terms of cost of care and in terms of quality, and all the other factors that are in there. We are trying to use AI to see if using this medication for this patient is associated with better outcomes. If you go to this kind of post-acute facility versus that kind of post-acute facility, does it impact the cost of care? I am hugely interested in exploring this as we go forward so that we can form this feedback loop with our providers to say, you’re doing really well here, and here are some areas where you can improve based on our analysis of data.

HIStalk Interviews Jodi Amendola, CEO, Amendola Communications

Jodi Amendola is co-founder and CEO of Amendola Communications.

Tell me about yourself and the company.

Amendola Communications is a full-service agency that focuses on healthcare, healthcare tech, and life sciences. I’ve been in the industry for over 30 years, always on the agency side. I have worked with all types of companies of all sizes and stages of development to help them differentiate from their competitors; tell their story; and meet their growth goals through strategic acquisitions, IPOs, or organic growth.

I’m also a Forbes Agency Council contributor, digital health judge, PR pro, marketer, and storyteller.  love working every day with my 25-member A team and our 45 to 50 clients in the space.

Are companies still focused on lead generation?

Lead generation has taken front and center stage over the past one or two years. It has been a tough market and the sales pipeline and the sales cycle has been delayed. Everybody has been super cautious and there’s that trickle-down effect. Lead generation has become more important than anything else in our toolset.

Having a good list that is targeted is the biggest differentiator I’m seeing. That spray-and-pray approach that we had many years ago doesn’t really work. 

Lead generation once implied posting gated content, such as white papers, that required recipients to first provide their contact information. Social channels such as LinkedIn and YouTube allow anyone to view content. How does lead generation work for companies whose content is out in the open?

Most of our clients do a balance of both. They both have a place. We still do gated content, the high-value content. But LinkedIn and videos are posted on YouTube all the time. They are just another channel, another vehicle for sharing your thought leadership in generating your brand awareness.

Companies often cut back on marketing and PR during those lean times you mentioned. How does that decision play out as business conditions improve?

I’m happy to report seeing a little bit of an uptick in activity starting just last month. I would say that in October, things started to turn around a little bit. People are preparing for 2025, but tough times do often lead to folks cutting. That’s a time where the wiser strategy would be to increase the spend.

So many clients are focusing on wanting to fuel the sales pipeline, generate awareness, and differentiate themselves, so that stop-and-start can really hurt them. PR and marketing rely on momentum and dominating the conversation, and if you step back, your competitors will step right in.

Another option during the difficult times would be to evaluate, strategize, and pivot to focus on the activities that are really working and take a more focused approach. Maybe cut a little bit, but be laser focused and targeted instead of just cutting everything.

Do companies sometimes design their PR and marketing campaigns around attracting investors or acquirers rather than customers?

Absolutely.  One of the first questions we ask is, what’s your end game? What is your goal? Is it to attract investors? Is it to get acquired? Is it to go IPO? We need to know that to know who the best target audiences are for their customized PR marketing program.

We have seen a lot of that this year. I personally have had a couple of clients get acquired. That’s hard, because we may lose a client if they get acquired by a big company. I’ve had clients over the years get acquired by Aetna, Philips, and Stryker, and those big machines usually have their own internal marketing and PR infrastructure. But absolutely, many clients point towards a specific goal when we start out.

How do you advise companies to participate in conferences?

With budgets tightening, people are more judicious about which shows they attend, and mostly, which shows they exhibit at. I just came back from HLTH, for example. I had 21 clients there, but only five had booths. That’s definitely a big change from years ago, where I would have 25 clients at HIMSS and all 25 had a booth.

Companies are focusing on which shows will give them the biggest bang for the buck. They are choosing between HIMSS and ViVE since they are only two weeks apart and it’s hard to justify resources for going to both.

You want to consider your target audience. A health tech company that has a lot of HIT customers might find that HIMSS is a better choice. HLTH might be a better choice for a health tech company that is actively looking for funding because it’s a more investor-focused show.

Companies also need to focus on smaller, more targeted shows that address niche solutions or that have a regional focus. HFMA and HIMSS have local regional shows. We have one client, for example, that focuses on Alzheimer’s, so they attend big conferences like HIMSS and HLTH, but they also attend several Alzheimer’s and dementia-focused conferences.

The cost of spending money for a booth is often reallocated these days to doing a nice networking event or hosting a happy hour or a dinner instead. That gets them out of the booth and gives them the ability to do more networking and to take a targeted approach to meet with the folks who are really important to them. That is a high priority during tough economic times.

I’m still seeing user conferences. I’m seeing clients that are doing their own events, webinars, and in-person meetings. It’s a great way to bring together their clients and their partners to collaborate, introduce new product launches, brainstorm, and then get good content and video that can be leveraged for PR and marketing.

How do you advise companies on using X and LinkedIn?

They absolutely need a strategy. LinkedIn has grown in importance over the last couple of years. X has really decreased, and in fact we barely ever create an X strategy for our clients any more. It may be repurposing what we’re doing on LinkedIn on X, but LinkedIn is where it is at. That’s where the decision-makers are. That’s where the conversations are happening. It’s a platform that allows you to be authentic and conversational and provide thought leadership.

The trick with LinkedIn is being consistent and having an ongoing presence. Not only on the corporate side, but having people who are important in the company showcasing the corporate account through their own personal accounts. I always say that people follow people.

How should companies tailor content so that doesn’t just get a lot of likes, but that also gets a message to the decision-makers who might actually buy their product or service?

There’s paid LinkedIn and organic LinkedIn. We do both, but the key is storytelling for engagement. LinkedIn is a two -way conversation. You have to engage with your targets with comments, likes, and posts, and you have to vary  your content.  You have to be consistent with your content. Share that you are a thought leader. Talk about lessons learned. You have to provide value and education instead of being self-serving . 

Every since TED talks caught on, we’ve heard about the value of storytelling, but LinkedIn posts are often dull truisms or gimmicky broad advice. How do you show individuality?

You can certainly repurpose articles, but share your point of view. That’s where the storytelling comes in. How does it solve your client’s pain points? Showcasing your expertise, maybe some of your success stories, advice, or lessons learned. Sharing surprising facts or presenting a challenge to engage them.

Treat it like a community. Don’t just post and expect engagement. You have to engage with them and hit them in different ways.

Today we really don’t advocate writing long white papers. People just don’t have the attention span. You want to hit them with something that’s impactful on social. It could be a video or poll. There’s lots of different approaches.

How do you recommend the use of podcasts or video interviews?

We definitely recommend doing podcasts and video interviews. We live in this multimedia-driven world, and people like sound bites and the option to listen or watch something versus read a long article. It’s the world that we are living in. It’s also a nice way for the CEO or whoever the thought leader is to express their insights and showcase their personality.

But you have to be cautious. You have to look at the details about the podcast or the video. How big is it? Who is the target audience? Because increasingly, podcasts are content marketing vehicles, and they may be positioned to look more like an independent channel or a media outlet. You want to make sure that the podcast is affiliated with a company that you’re OK with. Then, listen to those podcasts. Listen to the previous interviews and see if it makes sense to you. 

Once you do the podcast, if it’s right for you, then we always recommend that our clients amplify the podcast on their corporate and personal LinkedIn channels. Leverage it everywhere, such as e-newsletters to customers and prospects, and on your website. The key is to keep it short. Keep it focused. Have them professionally done. It’s positive because video content on LinkedIn increases linger time, which can improve a company’s LinkedIn metrics. 

How is AI being used in PR and marketing work? 

Just as AI tools are growing in popularity in healthcare, they are definitely advancing in marketing and PR, and I think they are here to stay. We use AI tools on a daily basis for identifying relevant journalists based on keywords from a press release, a thought leadership pitch, or transcription from an intake call or meeting.

We can build from that, but PR is relationship-based. We leverage our long-term relationships with the media. Sometimes we can supplement that approach and connect with a new member of the media. Some of our team members use generative AI for getting their creative juices going, like for research, ideation, and facilitating their writing thought process. But nothing can replace the brains of our writers or our PR pros, at least not yet. 

We know that hallucinations that can occur with tools like ChatGPT, where the tool says something that’s incorrect, but states it in an authoritative way. That can be dangerous. And as you know because you accept submitted articles, there’s definitely the risk of plagiarism. Some of these tools are pulling information together from multiple sources without any citations. This creates legal and ethical implications if you don’t use duplicate copy checkers. We use AI, but with caution.

Consumer-focused companies create buyer personas, then test and target their message. Does that work in the limited universe of health systems?

Absolutely. You have to start with the buyer persona. If you don’t know who your buyer is, then how are you going to target them? Very often clients know who their buyers are and flesh out the buyer personas. Sometimes there’s the actual buyer and then the influencers of that buyer, so we need to have at two -pronged approach in reaching both of them.

Then the trick is the messaging to those audiences. What is the value proposition to those buyer personas? Companies usually have multiple target audiences, so it’s understanding the value that they bring, how they solve those pain points, and then being able to promote their story to solve those pain points. But in a concise way. It’s like the elevator pitch. If you ask somebody what they do, they should be able to tell you in just a couple of sentences and not ramble on and on.

What are companies asking you to do for them over the next year or two?

This year we’ve seen a lot of integrated marketing campaigns. A campaign approach with all facets, such as social media, PR, lead gen, and digital, combined into one consolidated program versus operating in silos or trying one area over another. It is staying on top of the latest LinkedIn algorithms, staying on top of the SEO algorithms, being different.

A lot of companies want to be different now, not just do the same old, same old, because budgets are tighter. I think things will open up a little bit, especially the first quarter of the year and as we get into trade show season. Metrics is really a game changer. Everybody wants consistency and metrics and to know how you’ve influenced the sales cycle.

HIStalk Interviews Kyle Kiser, CEO, Arrive Health

Kyle Kiser is CEO of Arrive Health.

Tell me about yourself and the company.

I’m in Year 10 with Arrive Health, having been around since the beginning as part of the original team. My background has primarily been in payer-facing digital health. I was an early employee at a couple of digital startups. Before that, Principal had an internal startup called Principal Wellness Company, which was a corporate wellness business, and I was a part of that. That’s probably where I caught the entrepreneurial bug, because it was this group of a few dozen people inside this tens of thousands of employees financial services business. We got to work on really interesting problems, work directly with customers, and move fast. There were some great leaders in that organization. That was the start of this interest and curiosity.

Arrive Health was previously known as RxRevu through mid-2022. Our founding story involves one of our co-founders, Dr. Kevin O ‘Brien, who is a physician in Denver. His mom came to him about her high out-of-pocket spend on meds. Like any son who has the capability to do so, he helped her. There were simple things that he could impact. Take this brand, break it into its generic parts. There’s a therapeutic alternative that you could use for this one that saves you money. Maybe one that you can pill split. 

He made a pretty significant impact on her monthly out-of-pocket cost for those meds. That inspired him to start doing this work in his clinic. Kevin wasn’t doing that because he was in a value-based agreement. He wasn’t doing that because he made more money for doing it. He just started to identify the real need that the only meds that work are the ones you can afford. He started tracking these things over time for his patients. That is the seed of what became the initial API, which then became a real-time benefit network that connects into the point of care. 

But it all started with Kevin wanting to help his mom. We have a mantra in the company, “Lucy Up.” That’s our way to say, raise your eyes to the mission and really remember why we’re here. Kevin’s mom’s name is Lucy. Everybody has somebody in their life, like Kevin did, who has had an experience with the healthcare system that’s too expensive, confusing, hard to navigate, or hard to access. That’s a very personal problem when it happens. We use Lucy Up as a mantra to make sure that we continue to take that problem personally. That has been a huge part of our story and what motivates everybody on our team.

From a business perspective, we offer a market-leading real-time benefit network. We connect to the point of care into the e-prescribing systems and the EHRs that are used by providers. We provide real-time, patient-specific, moment in time, specific insight into the cost of medications.

That has evolved since we last spoke. We’ve built some interesting prior authorization tools. We bought a company from UPMC that was doing some interesting work around medication management and adherence in concert with the health system access team. We expanded beyond just the point-of-care price transparency piece, which is still a huge focus and important primary part of what we’re doing, but it also enables lots of other opportunities to solve new affordability problems and to solve access issues around prior auth. We’re pursuing those things with all of our might right now.

When a patient leaves their physician visit knowing that their prescription has been sent off to their preferred pharmacy, what unpleasant surprises might await them at the pharmacy counter?

The key point is that the primary cause of non-adherence is cost. Patient cost is a lot more complicated problem to solve than it used to be. Deductibles used to be hundreds of dollars, but now they are multiple thousands of dollars. Out-of -pocket costs around drugs went from $5, $10, or $20 to hundreds and thousands of dollars and even more in some rare cases. The consequences of the wrong choice are much higher for patients. 

At the same time, the complexity that physicians have to manage is way higher. Think about biosimilars, which have great promise. A lot of the health plans and PBMs are making specific choices around the right biosimilar, so now you’re going to end up in an environment where there’s a branded med, there’s a biosimilar option, or there are multiple biosimilar options to choose from, and those choices are different based on payer, PBM, or the type of insurance.

It used to be that if you talked to a provider, they probably knew that this drug makes the most sense for Blue Cross patients and this other one makes sense for these other patients. Now the complexity of that is not something that providers can manage in their head. It’s a problem that requires a piece of technology to help manage, because the complexity is so high and the consequences of a choice that is not aligned appropriately with the patient’s insurance, or when a cash pay option is more important, or when a patient may need some type of other support, means hundreds and thousands of dollars to the patient. 

When half of Americans can’t endure an unexpected thousand-dollar expense, the stakes are pretty high. That’s the way we are thinking about the problem. The stakes are higher for the patients, the complexity is higher for the provider, and we have to show up with both the right connectivity and the right type of technology that brings to the table the intelligence of a pharmacist in real time to be able to meet that need.

Does the problem flare up on January 1 when patients might change insurance or plans, meaning that their maintenance meds might require a new prior authorization, coverage for the med might change, and their deductible resets?

A lot of changes happen around the first of the year. October 1 is another important moment with a lot of anniversaries for insurance. Changes in plan design make a big impact. Those happen on certain intervals, and those intervals create spikes in those types of changes. That’s only going to get more complicated as the Inflation Reduction Act impacts Medicare and the plan provisions inside of Medicare.

We are only making things more complicated. In some cases, with good intent, not complicated for the sake of complicated. We’re trying to solve problems and there are only so many levers to do it, but it makes the job of the prescriber much harder, which is what we are focused on. How we clear the path for that provider to make a clinical choice that makes sense and focus on the clinical visit with that patient. Try to take the burden of this background web of complexity out of that equation, to the extent that we can, and just serve up what makes sense based on what we can see in our system.

You mentioned biosimilars, which hold promise to reduce the costs of big-ticket drugs such as Humira. Uptake seems to have been slow, maybe because the doctor needs to generate a new prescription since it’s not a simple generic substitution. What lessons has this process offered?

The lesson is that things really do take some time to work their way through the system. The primary regulatable insurance types, like Medicare, can be impacted broadly by a regulatory choice. Commercial insurance is an entirely different animal, and much of that is self-funded employers. That change has to be adopted employer by employer by employer by employer by employer. The web of decision-making there is that brokers and consultants are involved, the health plan is involved, and there’s the plan sponsor themselves. There’s a lot of different decision makers along that chain, so it takes a while for things to work their way through the system. That’s one thing, and then once they do work their way through the system, we have to communicate that to providers and care teams so that they can help guide patients through that newly formed maze.

Will 21st Century Cures and broader interoperability help with payer-provider-patient communication?

It’s a mix. There are some great success stories, with real-time benefit among them. We benefited from a CMS rule that caused some great adoption of real-time benefit technologies on the health plan and health IT side. That’s a good news story about positive impact.

There’s still a bit of adoption happening around Cures, but it not going to happen in abstract. The distinction is that real-time benefit had a discrete use case with a problem to solve. Docs want to know how much things cost and they want to do that so they can help patients. We could move into that space, which requires interoperability and requires providers, health plans, and technology companies working more closely together. That works well. The things that are important, infrastructure like Cures to change the way we operate, require useful use cases to then drive them forward.

Some of the prior authorization rules are good momentum in that direction. That’s where everybody stands to benefit from doing that better and differently. It costs health plans a ton of money to administer prior auths, but at the same time, they feel like they can’t really reduce the complexity of prior auth because it’s an important tool for them. Providers and patients bear the burden of how challenging that can be. They’re the ones completing the prior auth, reworking medication choices, and from a patient perspective, trying to figure out what’s going on. It’s one of those things where prior auth is a powerful use case to drive forward some of the interoperability ambition in a discrete use case that will benefit everybody.

What’s the balance between insurers using PA to reduce their costs while requiring clinicians to perform free work to send them PA documentation? Could that be done electronically, or will AI play a role and perhaps even result in the AI systems of both parties arguing with each other?

That seems to be happening now. The AI systems that are pitted against each other is probably current state in some cases. PA is definitely one of those universal things that everybody agrees needs to be different.

AI is a great opportunity to make that different. There will be a role for payers, EMRs, and providers to operate differently together. Doing things like indexing the clinical data in a form that allows you to autocomplete prior auth is a no-brainer. It should happen, it is happening, and I think it will be adopted quickly. 

One of the things that we are focused on, which is a little bit different than that, is how to take some of those policies and turn them into decision support. Every prior auth has documentation associated, where the health plan says, “Here are the rules of the road” for prescribing whatever it is you want to prescribe. This is probably not totally fair, but my guess is that the last person who read that policy is the one who wrote it. 

The way the world works today is that providers submit everything and see what happens. They’ve been trained to do that, because the decision-making seems invisible to them. We want to turn that policy into decision support. We integrate directly into decision-making workflows so that we can start much in the same way that we did with real-time benefit. Let’s get the answer right the first time and guide that to the appropriate path based on the criteria that the payer requires, because then patients are more adherent. 

I’ve heard estimates that one-third of patients just walk away when they experience a prior auth. That’s not great. We’re going to do this in a way that’s less burdensome to the provider and less consequential to the patient.

We’re going to reduce the waste that is associated with the payer experience. They probably have to deny a majority of what’s submitted, which we can avoid if we get that criteria into the hands of the decision maker. That’s where we’re focused and that’s what I’m most excited about, because if we do that right, a system embedded in the EMR that’s a guidance system could be a scenario where prior auths are no longer required. If we can get adoption of that type of tool at a broad scale the way we have with real-time benefit, we can go to those payers and say, not only are they following these guidelines, they’re using this tool to do so, it’s auditable, and we can show you. Then we can start to ask for a gold carding scenario, where prescribers maybe won’t be subjected to prior auth because they are using these types of tools. 

That’s where I want to go, because PA is one of those things that we all assume has always been a part of American healthcare. The first PAs were not even introduced until the late 1990s, maybe mid 1990s. It has not always been this way. It doesn’t have to always be this way. We just need the tools to behave differently, and that’s where we’re focused.

Big corporations operate drug stores, specialty pharmacies, health insurance plans, pharmacy benefit managers, and in the case of UnitedHealth Group, all of the above. Can technology improve transparency in a system that was built around the profit motive and vertical integration?

There’s still a lot of really good and important problems to solve for patients in the existing system and in the existing structure. The profit motive certainly informs a desire to build bigger organizations, more consolidated organizations. But at a plan sponsor level, they are still incentivized to try to control cost and get the best quality care at lowest cost. There’s plenty of room to run on making the experience better, on creating more consumer choice. 

We’re seeing a ton of progress there on driving more consumer choice at the point of care and throughout the patient experience. There’s more acceptance of just “that’s the way that is.” Some of those things are not necessarily our business so this is me commenting on industry generally. There’s things like integrated cash card programs that are being adopted by some of those people that you’ve mentioned that take insurance benefits and cash pay and start to compare those things, which is kind of the way it should work.

Like inside the deductible, you’re more often than not having to pay out of pocket. The in-network negotiated price list was intended to do a calculation to come up with a co-insurance number, not intended as the cash price. That has created the opportunity for these cash card programs and discount card programs. The integration of the benefit design and cash options is happening.  Some of the regulations that relieve the restrictions that some pharmacies have on guiding on that have been helpful. 

There’s plenty of plenty of places to make progress. If I were president of the universe today and could make the consolidation different, would I? Maybe. But we have to stand to where we are and make progress in the environment in which we exist. There’s lots of problems to solve for patients and plan sponsors in today’s environment.

What is the company’s strategy for the next few years?

A lot of it is the prior auth story we were just talking about. There’s a ton of opportunity to take on that space in a new way. That can also be working closely with some of the incumbents. 

Prior auth is a big part of the future strategy,and expanding our definition of affordability is how I would also characterize our other strategic focus. How do we make sure that we’re getting best price for patients? That might be alternative ways to pay, that might be pharmacy selection, that might be guidance within the plan design. All of those things are relevant. 

It’s about that type of consumer choice at the point of care and throughout the patient experience. That’s a huge part of our future. In the three- to five-year time horizon, we’ve been in a point of care connected price transparency environment, a real-time benefit environment. We are moving to a point of care care team integrated environment. That’s a lot of the work that we’re doing today. Where I want it to go is a consumer-facing type of experience and enabling that experience to happen.

An empowered consumer will make a huge difference. Over the last 20 years, e-prescribing actually reduced consumer choice. That’s the only time I can think of where we adopted a technology and the flexibility to choose and understand choice went down. You went from being able to take your paper prescription wherever you wanted to to being constrained by an e-prescribing system that just tells you to go to a pharmacy, then find out what it is when you get there. I want to help evolve our industry to be fully invested in empowering consumers in that process again. The technology is there. 

The promise of things like LLMs and generative AI enable that even further, and to your point around interoperability, the framework that is required to accomplish that is in place. It’s really just about starting to execute on that. 

Providers are important stewards. We will always be focused on that patient-provider relationship because it’s the most important leverage point for positive change. We have to continue to expand that to empower consumers to make choices around some of the things I’ve mentioned — how to navigate plan design, how to choose pharmacies, and how to understand their alternatives as it relates to payment. Those are all the places that we’re going.

HIStalk Interviews Ashley Womack, CEO, Aptarro

Ashley Womack is CEO of Aptarro, the newly renamed Alpha II. 

Tell me about yourself and the company.

I started my career about 25 years ago. I was originally in corporate restructuring. I did turnaround work for companies, both in and out of court. I’ve spent most of my career in finance leadership roles.

About a decade ago, I decided to make the jump to running high-growth businesses. There’s a surprising overlap between distressed businesses and high-growth businesses. You have to make fast decisions and execute with a maniacal focus on results, which is near and dear to my heart. The important thing for us is to look for unique opportunities that may not have already been fully realized, which can cause people to either fail or grow. I find the growing part more fun than failing parts and it has been a good move for me.

Aptarro is our new brand after we brought Alpha II and RCxRules together as a software company.  We help healthcare organizations break through the complexity of billing and help make it easier for people to get paid for the care that they’ve already provided.

What are the advantages of your products over those of competitors?

Our core products are around claim scrubbing and claims accuracy. The legacy product is called Claim Staker. The RCx products are revenue cycle engine and we have an HCC coding platform.

From a competitive perspective, everybody has some kind of solution for claims accuracy. Some kind. Doesn’t mean they have a good kind. They just have a kind of solution. Because we are very clearly fully focused on that little slice of the midsection of revenue cycle, we’re really good at it. We have great accuracy in terms of content and  staying up to speed hourly on content changes.

We have a workflow automation tool that helps billers and coders be more efficient. It autocorrects a lot of things that we know with certainty should be changed, and helps prioritize other problems that need to be worked by people so they can stay focused on the more interesting, complex stuff and that with the biggest ROI.

From a competitive perspective, we overlap with specific point solutions, but the biggest competitor is that people just use the thing that’s the freebie that comes with their PM or EHR. Because it’s like one of a list of things, it’s not necessarily as focused on accuracy or automation as we are.

What are the most significant recent or upcoming RCM technology developments?

The revenue cycle business is ripe for technology disruption. Everybody talks about AI and other kinds of advanced learning technology. Those work best when you have a lot of complexity and a lot of volatility, which is what revenue cycle is all about.

We are focused on thinking about ways to both improve the accuracy of content, which is important for what we do, and how to be more efficient. Staff efficiency and reducing repetitive or low-value work stresses out the people who do revenue cycle and makes that job less fun than it should be. We are thinking about how to use next-level technologies to target both of those areas.

Will we see more linking of provider and payer systems to address RCM-related workflows?

Why not? That’s the issue that is frustrating to all of us just as patients. I recently had ankle surgery, and I’ve had a lot of frustrations with the healthcare system as a patient. For providers, those of us who are in the revenue cycle, and maybe or maybe not on the payer side, is it just takes too long. It’s too complex. It’s too disjointed. People are not on a level playing field.

It would be a great end state if we could figure out how to make sure that everybody has the access to the same information and the same decision-making tools. If we create more clarity and transparency, things could move faster, people could get paid more quickly and fairly for the work that’s being done, and patients could get the treatment they deserve.

What were the lessons learned from the Change Healthcare cyberattack?

So many lessons. I have near and dear to my heart cybersecurity, governance, and thinking about making sure that we are safeguarding all of the information that we’re stewards of in this business. I’m sure that is top of mind for everybody. But if we step beyond that, it’s about making sure that you understand your technology ecosystem and avoid being too single threaded. As the buyer of these technology solutions, you have to understand what your choices are, how to make the right choices, and where you have opportunities and options.

Folks were forced to make big changes after Change. Those changes should be a little bit easier. Technologies should plug in with each other a little bit more easily and be a little bit more standardized. It goes back to the earlier point about should or shouldn’t we shouldn’t we connect providers and payers. There needs to be more standardization and a better understanding of what’s happening with the data and not relying so much on third parties.

One of the great things about our technology is that we are agnostic to which PMs or EHRs that our providers use. We can plug in anywhere. Our goal is to provide the best accuracy and the best staff efficiency regardless of what your other ecosystem choices have been.

Did it raise issues around switching costs, especially for smaller practices?

Doctors didn’t go to medical school to be IT guys or medical billers. It’s understandable that it has been a challenge. Even running a software business, making a big change like that is a challenge. To me, the lesson learned is maybe a bigger global thought about the industry. People maybe are not as forward thinking. Technology has obviously changed tremendously over the last 20 years. People have gone to more cloud -based systems. Things are a little bit easier to plug in, implement, and change.

Not all providers are quite there yet, and there are many reasons. Some of it is security reticence. Some is the cost of making the change, both the economic cost and the heartache, which is not to be discounted. But I think that folks are realizing that they need  more flexibility, and with on-premise, highly complex, or highly unusual setups, it’s not as easy to make a change.

How are investor-owned provider groups using technology and doing RCM differently?

There’s not one way to do things. There are definitely pros to having a variety of types of providers in the community for different folks, but I think some lessons can be learned from those investor-backed practices. The whole reason that investors are rolling those practices up is to try to make them more efficient and make them more profitable. That’s how they ultimately make money on them. If people can leverage those same types of tactics to make their own independently owned business more efficient and more profitable, why not? 

One of those is definitely around technology. How to simplify the tech stack, how to make it more efficient, and how to focus on ROI and think about making sure that you are making the right choices in vendor and choosing solutions that have a pretty clear ROI. Revenue cycle is obviously where all the money is moving back and forth. It’s important to think about you make that more accurate and faster so that your working capital cycle is shorter, you get paid more quickly, and you get paid for all of the work that you do. There are lessons to be learned there in choosing the right tech stack and getting the bang for your buck.

How do you as a company determine how to use ever-changing AI to improve administrative functions?

We have started by thinking about defining our strategy, creating governance around it, and creating a high-level, principle -based strategy around what we think AI should be doing and what should it not be doing. With medical billing and coding, and certainly around patient care, some decisions need to be made by humans  Even when it comes to stuff like claims processing, claims accuracy, changing codes, and things like that, we’ve taken a big step back and thought about what we want to outsource to the computer and what we think is important to leave to human judgment.

We started with those principles to then create a map of the biggest problems that we think exist in the universe that we’re operating in and how technology can support us in solving those problems, either with better answers or less expensive answers for our customers. That’s how we are laying out an AI roadmap around what we build and how we potentially partner with other businesses that we can go to market with.

 How do you as a former CFO run a business differently than someone whose background is operations, sales, or technology? 

I grew up working with businesses that were in some type of transformation. Not always in distress, but some kind of transformation. Every business leader, regardless of their discipline, needs a strong foundation in understanding the finances of the business. That’s what it’s all about. How do we solve a problem in a way that is valuable to the customer and is also valuable to the business?

If you can’t get a good handle on thinking through the numbers, it’s hard to make good business decisions, good strategic decisions, good decisions about how to invest, how to grow the business, how to build new technology, how to hire new folks, how to scale. I would hope that it’s not that different because a lot of executive leaders, and certainly the best ones, are well steeped in thinking about the numbers.

I think about building a business as building a team. I’m kind of a healthcare newbie, and certainly there are challenges to that. But I think it’s really important to surround ourselves with good people who are both industry experts and experts in their discipline. Coming up through finance is a little bit unusual, but it reinforces that it takes a team to win.

What does the next three or four years look like for the company?

We’re on the doorstep of the first big change. We’ve just done a significant rebranding and, changed the company’s name to Aptarro. The purpose there was to reposition ourselves and clarify our position in the market. The businesses that we brought together have all been around for quite some time, and there are pros and cons to that. But as we are approaching this next phase, we want to make sure that people understand the problems we’re solving, which are around  breaking through the complexity of healthcare billing and making it easier for providers to get paid accurately and easily for the work that they are already doing to care for patients.

This rebranding is about being able to clarify that across a couple of different offerings. We’ve brought three businesses together over the last couple of years and expect that we’ll continue to buy businesses and grow. We’re focused on that mid segment of the revenue cycle and helping make sure that claims are right and people are getting paid. That’s going to be a combination of product innovation, some of what we talked about around AI and technology, and traditional product innovation. We will be building things and potentially buying businesses and buying new products that make sense to help our customers solve the problems that are out there.

I think it’s an enduring health care trend that it’s hard to get paid. Providers did not go to medical school to become billers or coders, and that’s why we have RCM businesses. We are thinking about how we can make that easier. How do we tackle the complexity for them? The rebranding is part of that. We will continue to scale, both in terms of products offered and the rest of our footprint.

HIStalk Interviews A. J. Loiacono, CEO, Capital Rx

A. J. Loiacono is CEO of Capital Rx.

Tell me about yourself and the company.

I have been in the pharmaceutical supply chain for 24 years. I’ve always had a special interest or focus in software development, which makes me kind of unique in my role.

Capital Rx has two main businesses. We are a full-service PBM, a pharmacy benefit manager, servicing self-insured payers such as employers, unions, and municipalities. The other side of our business is that we are a PBA, a pharmacy benefit administrator, and we license our software and technology services to health plans.

What role does technology play in those two business lines and how advanced is it?

This has been an oversight for much of healthcare for far too long. The massive underinvestment in technology is catching up with the country. 

People think that there has been investment in healthcare. What I explain is that there are two major electronic workflows when it comes to healthcare in the United States. I’m generalizing, but one is the EMR-EHR, the electronic health record systems. This is the workflow to activate a claim, such as scheduling and decision support software. But the moment a medication is prescribed or a procedure is performed for a patient, congratulations, in the US healthcare system, you have created a claim. 

That claim then disappears from the very workflow that we have been describing. It moves over to my world, which is what we call claim administration, the workflow to administrate a claim. Who is eligible for the benefit? Who’s in network? What’s the plan design? What’s the co-pay? Who is being billed? Who is being reimbursed? 

On this side of the fence, we have invested nothing in over the last 20 years. This bill of technical debt or ignorance has caught up with the entire industry, because administrative workflows enable us to use new ideas to leverage new clinical ideas. If you have a brilliant healthcare idea, good luck implementing it, because the infrastructure or the technology won’t support it. This massive underinvestment is one of the key areas that’s holding back the country.

How can technology address the key issues of drug transparency and cost?

Let’s start first with price transparency. You are really talking about an innovative payment workflow or an innovative pricing workflow when you talk transparency. Because up to this point, one of the things that’s very odd about the prescription healthcare process in the United States is that no one knows what the real price of anything is. A lot of times, that’s because price may be obfuscated by co-pay. If you pay a flat $10 or $20, you don’t know or necessarily care what the price of the drug is. But with high-deductible plans or co-insurance over the last 20 years, patients have become more and more exposed to price. Patients start to feel the cost. It’s no longer hidden behind flat co-pays.

When we talk about technology, what you’re trying to do is allow buyers and sellers to freely communicate on price. What do we mean by that? The buyers are the patients, but really the buyers are what I would call the ultimate payers. These are the people that are plan sponsors or people that are providing benefit services on behalf of patients. The sellers are the pharmacies, but it’s a little bit more complex in the US healthcare system because the pharmacies don’t really have a direct negotiation with the patient. It’s coming through some form of insurance, again through a PBM or a carrier. 

By allowing the buy side, if you will — the patient — to freely communicate with the seller who’s really selling the drug — the inventory is held by the pharmacy — you create market efficiency. That sounds simple, but it’s difficult to manage inventories of 140,000-plus unique drug codes and to evaluate price based upon different benchmarking, wholesaling, and resale kind of pressure points. What hasn’t existed in the United States is an efficient market around drugs. It has been hidden. It’s been far too opaque.

This leads to the second problem, which is that the person that’s administrating the pharmacy benefit became conflicted along the way. This is the problem with the traditional PBM model. If you went in a time machine with me back to the 1990s, PBMs didn’t make money on drug spend. Their job was to be an unbiased administrator of drug spend. Very easy. 

Then in the 21st century, they shifted their model and said, there’s no longer a flat fee. My services are effectively free. We know that nothing is free, so how are they getting paid? The statement was, “We’re making a little bit of money on the drug spend.” People thought that seemed reasonable. But the inherent conflict of interest under that model is that the moment you start making money on drug spend, the more expensive the drug, the more money you make. The more fraud, the more waste, the more abuse, unfortunately, the more money you can make. 

Because of this inherent conflict, the industry started to adopt more opacity, more confusion, and more limitations around data, because the people that are making money on drug spend don’t want people to understand true price. Capital Rx took a different approach. We said, we’re not going to make money on drug spend. We’re not going to have any fulfillment assets, which means that we’re not going to own pharmacies, mail, retail, specialty. We’re not going to own or buy into a GPO. Our job is to let buyers and sellers communicate a price. 

Here’s where the technology comes in. The technology needs to create efficiency to transmit price, not just on behalf of the plan sponsor, but to the patient. To also help the patient that may have unfortunately been put in a situation where they’re using a medication that’s far too expensive and there’s a generic or a lower-cost alternative available, but there was never any interest under a traditional PBM model because of the inherent conflict of interest.

If you have delegated the administrative power to a PBM as a self-insured employer or plan, and if your PBM can make money on an error that is not in the best interest of your plan or patient, you need to change that model.

Companies such as CVS and Optum that operate PBMs have vertically integrated to own insurers, specialty pharmacies, and traditional pharmacies. How do they spread the total cost of a drug over those businesses to optimize corporate profit?

At the turn of the century, PBMs decided to move to a model where they made money on drugs. It’s the perfect model. Why would you change anything? It’s an inelastic demand curve. Patient utilization does not budge in the United States. Prices only appear to inflate, with list price increasing every year and the average cost per prescription goes up due to the proliferation of more expensive specialty drugs. 

When you have the perfect market, you don’t innovate, you consolidate. You not only buy more of the PBM model, you buy more of the supply chain. This is exactly what we saw. It’s not just the PBM buying retail assets, but buying mail assets, specialty assets, rebate GPO assets, and now even further with medical assets in the form of the actual insurance carrier, but even down to the physician level, buying entire surgical or physician practices. This is such a problem in the United States. It’s something that we need to focus on more than anything else, which is that vertical integration is a real problem.

The ultimate payer is usually the employer that provides health insurance. How can they empower themselves to force change on these huge healthcare corporations?

It’s very easy. The solution is in front of everyone. Very simply, If you want someone to administrate your benefit plan, that’s all they can do.

Let’s say I’m a big vertically integrated PBM and I want to be your administrator. I want to administrate your benefit plan. You as the employer say, that’s great, you can administrate my pharmacy benefit plan. But we can’t use any of your fulfillment, GPO, or other vertically integrated assets, because I need to separate church and state, if you will. I need to make sure that my administrator remains unbiased and unconflicted. 

The reason for this is that the moment you make money on drug spend, unfortunately, there’s an inherent bias in every decision. Be it there or not, you’re making more money on the actual drug itself. As the administrator, you need to push them and say, you can only administrate my plan. I could go to another PBM and say, hey, I’d like to use your mail facility, and I’d like to use maybe even a different entity’s rebates.

What we need to do is to peel away the things that are creating the potential for financial incentives to drive the wrong decision on behalf of a payer. I keep going back to this point, which is that if your PBM makes a mistake — I used a different pharmacy, I chose a different drug, I chose the different classification system, I applied the wrong DAW code — if your PBM can make more money, that’s a problem. By separating mail, specialty, and retail outside of the administrator’s financial purview or gain, I’ve created an aligned arrangement. My new administrator that’s just administrating services is beyond reproach. There will always be mistakes in any healthcare setting, but you can’t point a finger and say that they’re making more money on that mistake. Once you separate these two things, magic happens for both the patients and the plan.

Are employers and health plans aware that they have alternatives? How do you promote the idea that PBMs come with a conflict of interest unless you take specific actions?

I’ve been saying this for seven years. I remember very clearly that I was in a meeting with a TPA and they were considering using our PBM. They said besides moral outrage, AJ, does your company really have anything to offer? I said, moral outrage? This is a real fiduciary problem if you’re not careful. The people that you are having administrate drug spend, plan design, clinical decisions, and network decisions on behalf of membership are making financial gain from potentially bad decisions. They were like, this doesn’t matter. 

We stayed true to our philosophy. We are a B corporation. We don’t make money on drug spend. We invested heavily in technology to create the infrastructure for the future. Lo and behold, it turns out that we were correct. Legislative pressure, both state and federal, suddenly started to appear about three or four years ago. You started to see regulatory scrutiny and oversight from the FTC, CMS, other areas. You suddenly see moral outrage from patients sharing stories of pain what I would say is real price inequality. You then also see the media covering these stories. Then it begins to culminate into lawsuits and litigation, where you see both J&J and Wells Fargo, unfortunately, being named in fiduciary cases, where it’s being suggested that they are not doing the right job by using what appears to be a pricing system that is highly variable and unfortunately selecting prices where there are lower prices available in the market. You start to see these tailwinds accelerate.

For our organization, we started with zero lives and a mission. Now going into our seventh year of operation, we service over 3 million employer membership around the country. These are Fortune 500 companies. These are some of the largest municipalities, unions, health systems, and universities. We’re very proud. We are thoughtful in the services that we’re providing. 

This is a tipping point moment where, for the first time, you’re seeing bigger and bigger employers say, enough is enough. I need an aligned administrator, PBM, and the market has more than enough willing participants to provide retail, mail, specialty, and rebates. This is exactly what we do. We do not own any of these assets. Our job is to provide access to the pricing and value that the market is willing to offer. It’s a simple model, but the reason it became so complex over the last 20-plus years is because there was too much self-interest driving the model.

How hard would it be for government or anyone else to look at the medication value chain to try to understand what parts affect spending and where profits or inefficiencies exist?

This is one of the things that makes this a clear example of pain and consumer discomfort. It’s easy for anyone — legislative side, regulatory side —  to say, could someone give me an example of drug spend not being a great experience in the United States? There’s millions of examples. 

The question then is, how do you synthesize what is wrong in the supply chain from manufacturer through wholesaler to retail pharmacy or mail order to the PBM or carrier to ultimately the ultimate payer, the plan sponsor, and then ultimately to the ultimate user, the patient? How do you make sense of such an overly complex system? This is what has made this such a difficult discussion.

The other thing is, think of all the people that are making money on the current model. A lot of people don’t want to see the good times change. It’s lonely trying to move such a huge industry in the right direction. Thankfully, there are other people that share a similar vision and are helping us push this industry in the right direction, and many of them are competitors. Some of them are allies in this position.

But the whole point is that there is a growing movement for change because the pain or the issues is clear. The solutions up to this point were not. Some of it, again, was hidden or dampened by people of self-interest that don’t want the model to move. But now you’re seeing people come to the table and saying, enough’s enough. There’s no reason we need to continue down this path. 

The simplest way to solve for this problem is to just separate church and state. In the old days, you could be a commercial bank, but you couldn’t also be an investment bank simultaneously with the same member of your banking system. By separating these things, you have clear separation of powers and you have removed all conflict. You can still use all the big-name players for retail, mail, specialty, fulfillment, and GPO, but they can’t be your administrator. Because the moment you make money on drug spend, all the wrong decisions can happen, and if there’s ever any error or oversight, a traditional PBM can make more money. That’s just liability for any fiduciary.

What issues will be important to the company in the next few years?

I’m a big believer in continuing to innovate. Companies that stay static are displaced over the long term. A big part of what we do at Capital Rx is not just work on the solutions that meet the demands of today’s healthcare system, but to be thoughtful, look to the future, and to continue to provide new services and new infrastructure to support not just our ideas, but what comes next. We are certainly not the architects of the future of healthcare. What I often say is that Capital Rx has the best infrastructure. We are the best plumbers in healthcare. We provide the infrastructure for what is going to come next. That’s where we continue to invest heavily. Not just to stay relevant, but to position a clear path for healthcare to evolve in a positive trend.

We are seeing the tailwind of legislative pressure, regulatory pressure, and the media. Bad things happen when you have someone on the buy side and the sell side. If you’re on the buy and the sell side, you represent yourself always. That’s the problem with the traditional PBM model. Through vertical integration, they represent themselves at every step of the supply chain. That is a recipe for disaster, and disaster in this case is defined by hyperinflating drugs and medication that is perceived to be too expensive for the average American to afford. It just needs to change.

HIStalk Interviews Bill Grana, CEO, HCTec

Bill Grana, JD, MBA is CEO of HCTec.

Tell me about yourself and the company.

I have been in tech for nearly 30 years as an entrepreneur and business operator, beginning in the first dot-com era. A lot of my experience over that time has been in the healthcare provider arena.

HCtec is an IT services firm that is focused exclusively on health systems and other healthcare specialty providers. Our reason for existing is to improve the health of the communities that our clients serve by optimizing and making their IT functions better.

What health tech trends are you seeing?

AI is obviously capturing a lot of media attention. That is probably followed somewhat closely by cybersecurity issues, where we saw some significant events just this year. But AI is capturing a lot of the buzz. Although I usually believe that things tend to unfold from a technology perspective a little bit more slowly than what people often think, my general instincts in this case are going to be wrong. AI is here, and its impact — not just in healthcare, but in many other industries — is going to be real.

We have a significant call center offering. Health systems outsource their call center and their service desk to us, Clearly that will be impacted by automation and AI. That also extends to other aspects of IT and to the EHR. You can see scenarios where EHR analysts, whether they be Epic or otherwise, will have much of the work that they do become automated over time. I’m typically not one to believe that there will be a major landslide in technology adoption, but I think it will come more quickly than many people think.

I’m also a big believer in robotics and the coupling of AI with robotics. That will have impact not just within healthcare, but in lots of other industries. When I say robotics, my vision is humanoid-like robots, not factory assembly line robots. I hope to see that within my lifetime, and I think that it’s just a matter of time before that becomes a reality in the business world and in our personal lives as well.

What kind of AI help do health systems ask for?

We don’t necessarily have a defined practice in that area. We have done a fair amount of work in the data and analytics arena. What we are seeing is that health systems are pouring the foundation, from a data management and data architecture perspective, so that they can take advantage of some of the promise of what AI has to offer. I’ll call it preliminary foundation work as opposed to actually helping to support and implement AI systems.

Will health systems buy off-the-shelf robots or hospital-specific ones, and will they require a services component?

They will be functional or use case specific. When I show up for my annual visit with my primary care doctor and I check in, much of that whole process has already become automated. But then the time that I spend with the medical assistant who weighs me — which is always a little bit of a scary proposition — takes my blood pressure, and asks me about all the medications or supplements that I’ve been taking and my general health since my last visit, you certainly could imagine that a humanoid-like robot could be doing all that work. From just a technology perspective, I don’t think we are that far away from those use cases being presented.

Is consumer-facing technology such as the digital front door still on the front burner of health systems?

That absolutely remains a focus for the clients that we work with. Making it easy for their patients, their customers if you will, to interact with the health system. That could be making appointment sand much of the interaction. The foundation is the patient portal to ask questions of their providers and receive reminders about upcoming appointments or health screenings that are needed. That first phase is already in place for many systems. When I interact with the various providers that I see, much of it is digital.

Will use of that technology be evenly distributed?

I think it will become fairly ubiquitous. Virtually everyone has a smartphone in some form or fashion today, and the cost of the technologies too has been driven down as they have matured. I don’t necessarily see a world from a technology perspective relative to healthcare where you have a division between have and have nots. Now that’s a totally separate issue when you’re talking about just access to care. That that remains a real challenge in many parts of our country that are significantly underserved from a healthcare perspective.

What expected and actual benefits have health systems seen from shifting technology to the cloud?

There’s one recent example that comes to my mind. We supported a client who was moving their Epic instance to AWS, one of maybe five or six examples of Epic on the AWS cloud. They are getting the benefit of not having to support all the overhead and infrastructure that comes with physical data centers, but there’s also a big security benefit. Taking your applications and infrastructure to cloud doesn’t mean that you are completely immune to cyber risks, but it definitely makes it easier to manage those risks.

How will the availability of technology expertise change from the shift to cloud as well as return-to-office mandates?

We are seeing a lot of flexibility, including in our own business. In some cases, fully remote teams and maybe leadership that comes into the office on a periodic basis. In almost all cases, some sort of hybrid system where people are expected to show up in the office two or three days a week and then work from home the remainder of the time. 

I have very mixed feelings about that. I guess I’m some somewhat old school and in the latter stages of my career, but I’m still a huge believer in the power and the value that comes from people getting together in a room and working through problems. Not that it can’t happen through tools like Zoom that we’re on today, but it’s more challenging. But I also leave open the possibility that maybe generationally, I’m beyond being able to see how you do that effectively.

Do customers ask specifically for remote help for go-live support and major projects to reduce travel costs? Or do you convince them that their chance of success is better if you’re allowed to send resources to their location?

It’s still limited in terms of the requirements, and clearly it depends upon the type of work that’s being done. You still see a lot of at-the-elbow support being provided in person, although we also do a fair amount of remote backup support. That has made our business easier, because pre -COVID, we typically needed to find consultants who were either in physical proximity to the clients or willing to get on a plane every week to go see those clients. Now that that has become less of a requirement, it makes finding that talent somewhat easier than it was previously.

Will return-to-work mandates change the available pool of consulting talent?

To me, it’s just such a personal thing. Some people desire interaction with their work colleagues more than others and will seek out opportunities that are either exclusively in office or some sort of hybrid arrangement. Others are fully comfortable working in a remote environment and as a virtual team member.

I have a son who will be 25 years old here shortly who is a software engineer for a health tech company. He really enjoys his job, but two years into it, he is craving the ability to actually work in an office. The company that he works for is fully remote. It’s located in a place that, for a single 25-year-old, is not the most attractive geography to move into. He has realized that there are probably some things that he’s missing, especially early in his career, from a mentorship perspective and observation perspective, that he just can’t get working fully remote. I think about my own career and how different it would have been if I hadn’t had the relationships and the mentors in a face-to face manner that I did when I was his age.

Will people who work remotely find themselves not promotable or not experienced in the right areas compared to their in-office co-workers?

That’s a really interesting question for people who want to move onward and upward. Will they find themselves limited by the fact that they are working remotely? Time will tell. It probably depends on the organization and the culture of that business as well. Plenty of very successful companies are working fully remote, and people have the same sorts of opportunities to advance their careers as they otherwise would if they have to come into the office in a more traditional way.

What are the new challenges and opportunities for health tech companies as broad business conditions change?

Many product companies missed the mark, but were able to get going when money was free and everyone was a genius. Irrespective of industry, those that don’t have clear product market in this financing environment are going to have a hard time taking it to the next level. Those that maybe haven’t demonstrated a ton of market penetration or revenue success, but do have strong product market fit, will be able to access capital and be successful in the markets that they’re focused on. Another way to say it is that good companies are not going to have any problem continuing to grow and do good things, and those that were able to get started because of the low interest rate environment that we were in are going to fall to the wayside.

What factors will be important in the company’s next few years?

We are excited about our positioning, even with the advent of AI and maybe certain aspects of what we do being fully automated. As we look into the future, technology is only going to play a greater role in healthcare than what it does today. We equate that to opportunity in our business. 

The key theme for us is growth, whether that is revenue growth or the number of clients. Growth is something that we talk about constantly. Our vision is to be the recognized leader in the healthcare IT services market as measured by three things — client satisfaction, client retention, and the financial performance of our business. We think that we will get there, first and foremost, by working to deeply understand the needs the IT services needs of our clients, their challenges, and their key strategic initiatives. That starts with relationship building and establishing credibility and trust. In a pure services business, that’s even more important than in a product or software business. 

We will work then to address our clients’ needs through our own service capability or the capabilities of our partners, We have never set out to be all things to the market from an IT services perspective. We believe in strategic partnerships. We have strong delivery practices, definitely a culture and commitment to high quality service. By doing that, we’ll see improvement in our client organizations, whether it be from an operational perspective, clinical perspective, or, in financial performance, which is critical for many of our health system clients. You read that half of all health systems today are still in the red at an operating level. Bringing them back to the black is part of what we’re trying to help them do. If we do those things well, we ought to thrive and continue to see meaningful growth in our business.

We feel very blessed — and I don’t typically like to use that word – and excited for the opportunity that we have to help our clients leverage and improve their technology environments in a way that helps them. Most of our clients are not-for-profit organizations. Technology could be a part of helping them realize their mission and their reason for being.

HIStalk Interviews Clay Ritchey, CEO, Verato

Clay Ritchey, MBA is CEO of Verato.

Tell me about yourself and the company.

I’ve spent the last 20 years in healthcare technology. One of the things that strikes me is that over that 20 years, we as an industry have spent billions of dollars digitizing healthcare and investing in digital transformation with the promise of having liquidity of healthcare data – getting it to the right place at the right time to improve outcomes and efficiency of care — only to realize that one of the biggest blockers of the success of that investment is identity. Being able to trust who the data belongs to and knowing who is who.

I got excited about joining Verato four years ago because we think of ourselves as the identity experts who enable better care everywhere by solving this problem that we believe drives everything else in healthcare, which is knowing who is who. We provide organizations with the tools to have a single source of truth for identity that enables this complete and trusted longitudinal view of the person, that single pane of glass that allows you to take all this data in your enterprise, make sense of it, and be able to trust who it belongs to so that you can get insight from it.

What is the business case for reconciling multiple identities of patients, members, and consumers?

The business case used to be around this idea of clinical interoperability. We had clinical systems, EHRs, that weren’t able to do a very good job of resolving identities, so that you had duplicate medical records, or maybe even overlays. The harm of that was either significant increased cost of things like doing duplicate procedures that you don’t need to do, or even worse, some type of sentinel event because you charted somebody else’s information on a patient record.

But as you think about 2024 and the challenges of the modern healthcare organization, we see that the business case is even more strategic. Most of our customers work with us because they’re trying to figure out how to plot a course for growth. Healthcare is just starting to think about consumer-oriented strategies and how they think of that.

A customer told me recently that they had a strategic offsite, where they decided that it is OK to call their patients consumers. That struck me since it gives us a sense of of how healthcare has had this challenge of thinking about investing in the types of tools and technologies that would enable them to understand the complete consumer experience. Tools that help them engage the consumer better, help them change their behavior, and help them consume the right services that they need for better outcomes. That’s where we see the biggest business case.

We’re in a world in 2024 where only one in four of those in the younger generations have a primary care physician. Primary care physicians historically have navigated patients into our into providers for referrals and high-value services. The emergency room is no longer a significant referral source, as urgent care pop-ups are taking more of that market share. We see more savvy consumers who want to search the internet for options for care and self-diagnosis. In that environment, we’re seeing this need to be better than ever at engaging consumers, and to do that, you have to know who is who and you have to do a better job of connecting the dots between all the engagement that you have with your consumers at all your touch points. That allows you to curate the best experience and the best care for them.

A lot of our customers think about, if I have a goal to double my revenue in five years, what infrastructure do I need to build to do that? That’s where they turn to Verato to help them figure out how to double their volume. If they don’t know who is who, they can’t engage consumers, retain them, and acquire them in a more frictionless way.

How is consumer identity management different from just matching up multiple sets of a patient’s records on internal systems, and how is healthcare different from other industries?

We’ve learned that historically, the problem that we have with consumer data and identity is that it’s often thinner information than you have for your clinical data. What you don’t want to do is pollute your clinical match by using less trustworthy data that you’re getting from marketing or consumer sources.

What we have done at Verato to solve that problem is that we have multi-tiered matching, which allows you to have different tiers of matching based on the trust level of your source. That allows you to associate these identities at a consumer level with maybe a clinical-grade identity that you have in your census, but without impacting  the way that you think about identifying that patient in a clinical way. You get the benefit of being able to associate the consumer data with somebody who you believe it belongs to, but at the same time, it doesn’t impact the quality of that match where you really have to get it right on the clinical side. That technology has allowed us to help organizations do a better job of landing consumer information and associate that consumer engagement with the patient with whom they already have a relationship.

How well are organizations using that type of technology?

We still see the industry as laggards when it comes to embracing and investing in modern technology that solves the modern problem of identity matching and resolution. The problem is no longer just about helping manage clinical identities inside of your clinical system. 

We think about three kinds of systems. One is systems of record, such as the EHR. Others are systems of experience, such as CRM, the marketing automation platform, or patient engagement tools or platforms. The third area is systems of insight that drive clinical and consumer insights around people, so things like cloud data platforms.

When you think about those very different systems, and you think about a modern platform or set of investments that you need to make sure that you’re able to share information across those different types of use cases, that’s where we think the modern investment needs to be made in a cloud-based tool that enables you to have a single pane of glass across all of these disparate sources of data and consumers of data. That’s where we’re seeing the marketplace, where provider health systems, payers, and even state and local governments are making investments based on this complexity of not just managing data internally in clinical systems, but also across these systems of insight and systems of experience. Then meeting the demands of all the folks who want to consume and share data outside of your organization.

There’s a whole different level of innovation required to understand and manage identities across that broader, more complex ecosystem. That’s where you’re seeing organizations start thinking about this next level of investment and data management platforms such as Verato’s.

Is there an opportunity to use AI to improve that process?

We are using AI in our platform today. We believe that AI can absolutely continue to help manage identity and identity attribution. We’re using AI today, for example, to make matches that we couldn’t have made otherwise. We are learning from the humans who are stewarding matches. We’re leveraging our AI to track and understand the behavior of humans and the matches that they are making manually. We have already been able to show 25% to 30% improvement on matches that we couldn’t make without AI based on that type of smart stewardship. That’s one area where we are seeing AI to be really, really helpful.

Second, we spend a lot of time making matches that aren’t intuitive, where it’s hard to see that these two records involve the same person. We are using AI also to explain to our customers how they can count on and trust that this match really is the same person. AI is being helpful of being able to connect the dots and show the breadcrumbs to those end users so that they can trust the match. It’s kind of counterintuitive, but we’re seeing AI as a tool to help provide more trust in these complex matches that we’re making by being able to help explain it.

Lastly, we think that AI more than anything is a great opportunity for us to drive a lot of productivity inside our organization in how we use AI to write better code and document that code.

With respect to identity resolution itself and how it might actually enable AI, that’s the other area we’re excited about. As I’m talking to a lot of our customers across the healthcare continuum, everybody has a strategic initiative around AI, mostly just trying to understand what their strategy should be and how can they thoughtfully and responsibly move forward towards that strategy. 

A lot of those folks are thinking about data fidelity being the starting point, because garbage in is garbage out, especially with AI. We’re all worried about about these hallucinations, and when AI gets it wrong, they really get it wrong and cause harm.  We are seeing an opportunity for organizations to first focus on the foundational elements of how to get high data fidelity so that you can train AI on data that you trust. That comes back to this basic premise of identity resolution, knowing who is who and being able to trust that the data set is longitudinal and accurate across all the touch points of that person.

What is the interest level in applying identity management to consumer-initiated inbound communication, such as calls to a contact center or conversations with a chatbot?

One of my favorite airlines is Delta. They do an amazing job in that when I call them, they know who I am, they know my history, they know my preferences, and they have already put me into a workflow that will most likely help solve my problem. Because they know who I am, they already know that maybe I just missed a flight and I need to have one rescheduled, and they have already started working on rescheduling that. 

How can you take advantage of a modern call center to not only improve outcomes, but also to become a source of revenue for your health system? We are seeing call centers leveraging tools like Verato to not only identify those who are calling or messaging, but to connect them accurately to their record so they can already be prepared to anticipate that customer’s call and help navigate them to help them where they’re going,

That can also address gaps in care. I call in today to deal with an appointment for myself. Wouldn’t it be great if that call center agent knows that I have three children in my home and two of those children have a gap in care? Maybe they missed their annual checkup. I would be able to close those gaps in care in one call while I have them on the phone. We think these are all great opportunities for identity resolution to be incorporated into the call center workflow experience so that we can better anticipate the needs of the caller and also better anticipate the needs of the other people in that caller’s household. That helps us drive revenue and close gaps in care.

Website user tracking allows big companies and social media to target advertising based on the person’s broader identity or persona. Are there techniques or lessons learned that could be used more noble purposes?

I think yes, but we believe and understand that many consumers and patients are giving up privacy for convenience, along the lines of our policies around consent and preferences. How do we as a society do a better job of allowing consumers to give more granular consent and more granular preferences around how their data will be used, consumed, and shared? Then we can all do a better job of leveraging that information in the right way to create a better experience for them.

Second is that 85% of the US population was uniquely identified in Verato’s platform last year. Through those workflows and experiences, we see a lot of demographic information about these patients. We are continuing to look for ways to get more control to not only to our customers, but also the patient on how that information is used. We want to think about granular consent and how we can be a single source of truth and enable more control by people of how their data can be used for convenience measures, but in a way that they are comfortable with from a privacy perspective.

A hot topic is insures or health systems maintaining accurate and current provider directories, which is harder when clinicians work at multiple facilities or hold multiple roles. How are health systems using provider data management technology?

The current state is pretty sad, in the sense that we find this problem to be even more challenging than patient identity and consumer identity. The state of accuracy of provider directories, their affiliations, and their ability to have open census that’s available where they are available to see new patients hasn’t really improved in the last 10 years.

I saw that last week that 57% of patients who are consuming an inaccurate provider directory results in revenue leaving that payer or that provider into outside their network. There’s all these negative consequences that are associated with not only the patient experience, but also revenue capture and revenue leakage for payers and providers. The stakes are pretty high in getting it wrong, but we still see a scenario where there isn’t a good single source of truth for provider identities and provider information.

We are applying our expertise in patient identity resolution to this big provider problem. We are already seeing a lot of opportunity to do so, not only in a sense of being able to be a single source of provider data that sits inside of an organization, but also a lot of the 85% of the population who comes through Verato is coming through large HIEs that we have relationships with. Those HIEs often have accurate, real-time data around providers and their affiliations, where they’re practicing, and what patients they are are seeing. We are looking for ways to tap into that type of data so that we can get more real time, accurate provider data that can hopefully solve this problem that has been elusive historically.

What are the company’s priorities over the next few years?

I mentioned earlier that our mission is enable better care everywhere by solving this problem that drives everything else, which is knowing who is who. Where I see healthcare going in the next three to five years, and where we want to get there ahead of them, is along these lines of interoperability outside of our customer organizations. 

Most of our customers leverage Verato to help them do a better job of managing data as it relates to people inside their organizations so that they can deliver better services to those patients more efficiently. Where we’re starting to invest in is thinking how we can also enable those flows of data outside of the organizations as interoperability across the care continuum becomes more of a reality and more of a must-have with the requirements like 21st Century Cures, information blocking rules, and the requirements for organizations to create better experiences for patients that are having experiences across payers, life sciences, and providers. We see an opportunity for us to invest there. We are working really hard on finding ways to enable that ecosystem to do a better job of being able to share identity information across the care continuum so that consumers and patients want their information to be shared and have better tools to do so with better reliance.

One of our customers recently told me that they have a bridge that connects a children’s hospital that is not affiliated with them to their to their acute care hospital. They often have patients walking across that bridge to consume services in their hospital from the children’s hospital. Both organizations use the same EHR, but even though they are connected with their bridge, the EHRs are not connected in the same way. Even though it’s the same EHR, they can’t share records in a way that they can depend on. They worked with Verato to take that very simple use case, same EHR but in different organizations, and use Verato as the bridge to enable that interoperable connectivity. Now when that patient comes across the bridge, they already know their history, why they are there, and where the referral came from. They are already  running towards delivering services to that patient. That’s a good example of the beginning of what we see, that Verato will be a part of this bigger interoperability play across the healthcare continuum.

HIStalk Interviews Frank McGillin, CEO, The Clinic by Cleveland Clinic

Frank McGillin, MBA is CEO of The Clinic by Cleveland Clinic.

Tell me about yourself and the company.

I’ve been in the CEO role of The Clinic by Cleveland Clinic for the last five years. We’re a joint venture between Cleveland Clinic and Amwell. Our mission is all about expanding access to Cleveland Clinic’s expertise by leveraging digital technology. My background is a combination of digital health as well as consumer healthcare.

How does the organization work with Amwell?

Cleveland Clinic is the majority shareholder of the joint venture and Amwell is a minority shareholder.

We have a close relationship with Amwell. We run our solution on Amwell’s Converge platform. We also do co-marketing and work through their sales channel. The partnership with Amwell has helped ensure that we have the tools and technology to make it easy for patients to access the expertise, as well as making it easy for the clinician to deliver the second opinion.

What motivates patients to seek a second opinion and what kinds of patients do so most often?

Typically an individual will seek a second opinion when they are faced with a consequential decision. They’ve gotten a cancer diagnosis, been told that they need surgery, or have a condition that isn’t getting better. They want to understand their options.

Second opinions have been going on for as long as medicine has been around, but the ease of getting a second opinion depended on who you know or where you are located. With the virtual second opinion program, we try to eliminate those speed bumps. Regardless of where you are based — whether it’s a rural county in the United States or whether you’re deployed with the State Department overseas — we can help you access that expert, whether it’s an oncologist, a cardiologist, a neurologist, or any other subspecialist to help you understand your treatment options, review the accuracy of the diagnosis, and present some of options for managing your condition moving forward.

Two-thirds of your second opinions result in a different diagnosis or recommend a change in the treatment plan, and patients usually accept those recommendations. Does that indicate that the original doctor made a mistake or that they did not have access to the right resources?

Various factors could drive a change in the diagnosis and the care pathway. With diagnosis, a typical or potential area would be a rare condition that local physicians don’t see regularly, so you can bring in a specialist who is dealing with those cases on a more regular basis. They are able to identify and diagnose more accurately. Sometimes it’s a matter of reinterpreting pathology and having subspecialist pathologists looking at the specimens and getting more specific in terms of the nature of the cancer type to ensure that we are targeting the right disease state with the right solutions.

In other cases, it could be a treatment option that is beyond the scope of a local care provider. We had a patient from the Pacific Northwest about a year ago who was told that she needed a heart transplant because of the advanced nature of her heart disease. In the second opinion, the Cleveland Clinic cardiologist identified this patient as being a candidate for stenting. The Cleveland Clinic cardiologists deal with the most complex cases in the world. They have experience stenting people with more advanced heart disease than potentially a regional hospital.

Finally, it’s about advances in care, whether it’s new approaches for radiation therapy or clinical trials that may be available for a cancer diagnosis.

Are patients surprised when their second opinion differs from the first one? How do they determine which one to trust?

Someone who is seeking a second opinion is looking for one of two things. One is the confidence and comfort that they are moving in the right direction, particularly if we’re talking surgical or other significant medical procedures. They want to have the confidence that they are going in the right direction. They want to have the confidence that it’s the right diagnosis.

Consumers are becoming more active in managing their healthcare with high-deductible plans. They are bearing more of the cost and are becoming more educated in leveraging health data online. But at the end of the day, they realize that if they are dealing with a significant health issue, they want to access the best expertise. 

With a virtual second opinion program, we eliminate the need to travel. We eliminate the need to do the research to figure out who is the best specialist match for you. We make it easy for you to get that peace of mind.

How do you collect and assemble the patient’s medical records and present them to the second-opinion physician for review?

Unfortunately, we’re not in a world where it’s universally easy to access medical records. Part of the benefit that we offer to the individual is that our team goes out and hunts down your medical records, your imaging, and your pathology, because without high-quality records, the specialist isn’t able to render a quality second opinion. In some cases, there is electronic data transfer from the EHR and we can get your records basically instantaneously. In other cases, we’re still getting faxes. We leverage technology where it’s available, but other times, we need to do the legwork to get it done.

On the back end, we’ve tried to make it easy for the clinicians to work it into their workflow. We’ve integrated our second opinion process into the EHR. When a specialist agrees to take on a case, that makes it easy because they are working in a workflow that is native to them and that lets them be efficient with their valuable time.

Is the process limited to a review of the existing records or does the physician ever decide that they need additional tests or information from the patient?

We are generally able to get sufficient data. As a second opinion program, in 99% of the cases, adequate testing has been done prior to the second opinion being rendered. There are cases where we will have to request some additional scans that may or may not have been done, or some additional testing to make sure that the specialist has all the information that they need to render a quality opinion.

Doctors often say that you treat the patient, not the data. Does the second opinion process devalue the patient’s self-assessment or their treatment goals that might not be reflected in tables of data?

Part of our process is that we do an in-depth onboarding interview with every patient who comes in through the program. It’s done with one of the registered nurses on our staff. During that intake, we ensure that we have a robust profile of that patient. What has their journey been in managing their own health, not just their most recent doctor visit? We try to understand the areas where they have questions or concerns. We are able to pull together a comprehensive profile before the Cleveland Clinic physician steps in to help with the second opinion.

In the majority of the country, we are also able to offer a video visit as part of the second opinion process. That’s dependent on whether we have a licensed specialist in the state where the person resides. Cleveland Clinic physicians have broad licensing and are able to meet that need for the majority of people who come through the program. That gives both the confidence and comfort as you are dealing with the specialist. For the specialist, it adds an extra layer of being able to evaluate the patient during that interaction.

What does the patient do with the second opinion’s recommendations? Is the regular physician looped into the consultation results to decide whether to make treatment changes?

At the completion of every second opinion, we deliver electronically to the patient, and generally also to their local provider, a written report that outlines the findings, recommendations, and suggested next steps. That provides a foundation for deciding where to go. That could be seeking a different approach, a more aggressive treatment approach, or a more conservative approach. It really depends on that individual.

Sometimes the recommendation is for a procedure that may not be available locally. In those cases, patients often transfer care, sometimes to Cleveland Clinic, but at other times to perhaps a academic medical center that’s in their own geography.

Do local physicians and health systems see the second opinion service as competitive or as an unwelcome review of their decisions? Does the patient tell their own doctor ahead of the time that they are seeking a second opinion?

We believe firmly that healthcare is a team sport and that you get the best outcomes with multidisciplinary teams. If you have a local physician who is not open to input from their peers, we think that should set off a red flag. We try to be collaborative. We will facilitate conversations between the treating physician and the Cleveland Clinic specialist if there are questions.

We see this as supplementing and providing additional level of expertise as opposed to competing. Unfortunately, there are some misaligned incentives. There are times where there are some recommendations for overtreatment. We may ruffle a few feathers, but at the end of the day, the recommendation that the Cleveland Clinic physician is providing is always what is in the best interest for that patient.

Do the physicians who render second opinions volunteer for that work? Do they carry out a normal practice as well?

We have a large cohort of Cleveland Clinic specialists who participate in the program. They all have day jobs, so they are all working day-in, day-out, whether it’s cardiac surgery or medical oncology. They’re doing this in addition to their normal clinical responsibilities.

There are a couple of drivers behind this. One is that they realize that there are care deserts out there. More than half of the counties in the US don’t have a cardiologist. They realize that Cleveland Clinic quality care is not available everywhere.

The other thing is that these are generally complex cases. They are interesting cases for clinicians at an academic medical center like Cleveland Clinic. There’s the motivation to be helping these patients with the most complex conditions.

What happens once the patient has completed the intake and initial paperwork?

Our process end to end is generally 10 to 14 days. It can go quicker if we’re able to get medical records instantaneously. But generally, the long pole in the tent is the medical record. After the nurse intake, we gather all the medical records, the imaging, pathology, and any other testing data that’s available. Our team assembles that electronically for ease of review by the Cleveland Clinic specialists. A lot of the value that we add is in matching the patient with the right specialist, the right subspecialist.

The typical consumer who is coming in just knows that they want the best. Often we’ll have people say, “I want Dr. Jones or Dr. Smith. I see that they are head of the department.” That actually may not be the best match based on their specific conditions. We put a lot of energy into the matching.

Once we match the patient and the physician, the review is usually one to two days as they are reviewing and preparing for the second opinion. They are drafting a written second opinion report. The bulk of the time, they will have a video consult with the patient. Then the patient receives the written second opinion report.

Much of the perceived value is the Clinic’s brand name and its lack of financial misalignment. Could that philosophy change how medical services are delivered generally?

I don’t think you can paint all physicians with the same brush. Cleveland Clinic physicians are all staff physicians. They have zero financial incentive to recommend anything other than what is in the best interest of the patient. Not all medical institutions operate with that same model. So part of it is the DNA of the Cleveland Clinic physician. Another part of it is that the second opinion program is one step removed, which also helps improve objectivity.

Based on that, we have been able to show that on average for employers and health plans, we are saving them $8,700 per patient or per employee who goes through the program. Those savings generally come down to avoiding unnecessary procedures, unnecessary surgery. 

It’s common for us to see a patient coming in who is scheduled for back surgery, but our review indicates that it isn’t necessary for the patient, and that less-invasive, more conservative approaches would be in that patient’s best interest. You can imagine not only the cost savings, but the personal impact of avoiding surgery and the ensuing recovery. 

What does the ability to render second opinions remotely using existing patient records mean for the future of healthcare?

As medicine advances, it becomes more specialized, more subspecialized. The mismatch between demand and availability of specialists will only get worse. We believe that digital tools and digital programs can be that force multiplier that would expand the reach of an individual specialist so that they can treat even larger populations. The digital tools also eliminate that need for the patient to travel to that specialist, so we can cover broader geographies.

We see a future where digital tools and programs leverage the specialists, the local physician, APPs, and pharmacists through integrated programs to help dramatically improve the health and wellbeing of large populations of people who are living with chronic disease and get them access to the care that they normally wouldn’t be able to access on their own.

About 800,000 Americans are misdiagnosed each year. Large swaths of the country don’t have access to high quality specialists. We believe that programs like the Second Opinion program by Cleveland Clinic help fill an important gap that not only saves money, but also makes a fundamental impact on the quality of people’s lives.

HIStalk Interviews Adam McMullin, CEO, AvaSure

Adam McMullin, MBA is CEO of AvaSure.

Tell me about yourself and the company.

I have led AvaSure for the past two years. I have had the privilege of being involved with a number of businesses that serve providers, working with nurses and improving clinical workflow. AvaSure checks all the boxes for me personally. It’s a mission-driven organization. It’s a company that is at the middle of a transformation around how virtual care is leveraged for providers.

AvaSure is the leading intelligent virtual care platform for hospitals. We have 1,200 of them as customers. That involves patient safety, virtual care, and ambient technologies that improve safety and efficiency.

What is the state of the art in virtual care and the technologies that enable it?

Our technologies were originally the purview of the chief nurse, who is an incredibly important constituent. We have a great chief nurse advisory board to help advise us there. But almost every health system has stepped back and realized that they have virtual safety, which is also called virtual sitting. They have efforts around virtual care and virtual nursing. They have traditional programs such as tele-stroke and tele-ICU. They are also thinking about the home. 

What platform that does that? You have a number of solutions that are converging to become a health system-wide platform that has evolved to do a few things. It needs to have stability across the base of the platform. It needs to work, because when you’re adopting virtual care technologies, you need utility-like performance. On top of it, the value propositions and the problems that are being addressed are very much about improving patient safety in bucket one. Virtual care broadly includes things like virtual nursing, rounding, E-ICUs, and the like.

The third leg of the stool after patient safety and virtual care is around ambient, which is emerging. We have technologies that leverage computer vision for falls reduction and patient elopement. We just acquired a business to further accelerate our efforts. 

We are seeing those three domains come together. Health systems want a platform that supports that and integrates with the rest of their technology, such as their EMR, their communication systems, and other AI technologies. There’s a lot of development in the market. Virtual nursing has continued to evolve as we look at the problem sets.

How does virtual care affect nurse satisfaction and the cost of providing nursing services?

We have virtual nursing in all of the cases that we have implemented. The experience from our chief nurse advisory board has been an improvement in nurse satisfaction and virtual care broadly. If you’re in the virtual safety arena and you’re not leveraging virtual safety observation, often you are taking away the non-licensed professionals who support nurses and care teams. Virtual safety observation contributes back to the care team. If you have virtual nursing and can triage, manage patient requests, or perform more thorough and less time-consuming patient discharges and admissions, then the nurses on the floor can better leverage the top of their licensure and focus on the patients that have acute and immediate needs.

Nurses want to be able to have deep connectivity with their patients and to spend the time that is necessary. But they might be in the middle of something that takes more time. They get urgent calls and emergent calls and are pulled away. We have seen nursing satisfaction improve across the board when virtual nursing is a part of the care delivery model. It’s not a brand new care delivery model. It becomes part of the team-based care delivery model.

Have hospitals found unexpected benefits or use cases once they deploy virtual sitters as an efficient, non-intrusive set of eyes on the patient room?

Virtual sitting is a nice, effective way to get on board with virtual care. It provides financial benefit and clinical benefit. As an example, Community Health Systems had zero falls with injury once we implemented in their hospitals. That’s a clinical and financial value proposition. You support things like falls and behavioral health, which then frees up resources that can be returned to the care team, and then fund the migration from virtual sitting — which started with mobile devices and rolling something into a room —  to this migration of enterprise-wide virtual care, where you are putting devices in every room. That supports those other use cases around broader virtual care and ambient.

Certain patients have a higher cognitive load and need more direct observation. We are also augmenting the virtual sitting with AI to improve effectiveness. We think that over time, the AI will advance to where you have a device in every room, and even if a patient is not being monitored by a human, we can provide an additional set of eyes on all patients. We’ve seen some interesting things as you leverage sitting and open the doors to virtual care, which then catalyzes these devices in every room that can then act as sensors. That is leveraging computer vision to do more, both clinically and operationally.

We provide our customers a maturity model around how these technologies are adopted. You can start in places that prove principles for the care teams, build confidence, and then move up the maturity model as you adopt additional use cases. We worked with both clinical and IT teams to inform that. The market maturity model it is not specific to AvaSure. It was developed in conjunction with leading clinicians and folks on the IT side. I’m thankful for all the health systems that contributed into it. It’s a useful roadmap that allows you to cut through all the noise and the fog to create a pathway to achieve the benefits of better clinical results, lower costs, and better utilization of precious human capital.

ICUs and other specialty units were mostly defined as a location that was wired for monitoring and staffed by specially trained employees. Will virtual solutions change that way of thinking?

We are all aware of the trend of rising acuity across health systems. We are seeing patients being kept in units when they might otherwise have been moved to higher-acuity units or prevented from moving to higher-acuity units.

I’ll give you an example. University of Colorado Health has published about their sepsis monitoring program that keeps people out of the ICUs. By having virtual monitoring, AI algorithm for detection, and well-trained and centralized human experts sitting in the virtual care center, they have saved 1,000 people per year from getting sepsis.

If they had sepsis or complications, they would be in the higher-acuity setting. By doing this, you are preventing issues and reducing length of stay overall, because people would be in those higher-acuity, more expensive settings and potentially be exposed to harm.

How does integration with the EHR work?

The EHR is obviously the core clinical system that we want to support and augment. Our technologies are integrated into all of the leading EHRs. In many of the EHRs, you can be in the clinical record, launch a virtual visit, and engage other providers if you’re doing a discharge. You can engage whoever is in charge of family care of the patient and loop them in from wherever they are outside the four walls of the hospital to have appropriate patient education or discharge. You can do all of that right from EHR.

We see a combination of the virtual care technologies that are tightly integrated with the EMR and other technologies that are working in the background to improve outcomes. We opened our platform. There’s so much innovation happening in this space, and we wanted our customers to know that AvaSure can support the things we do in safety, virtual care, and with computer vision and ambient. There’s a huge ecosystem out there. 

We have a partnership with a company called Clew, which is the first FDA-cleared predictive model for patient deterioration. They have seen examples where alerts and alarms are reduced by 50 times. With that combination of video and documentation in the EHR, you’re see some incredible outcomes. UCHealth is using the Epic model as they support their sepsis reduction. Virtual care augments and supports the EMR.

How will the acquisition of Ouva affect AvaSure’s capabilities and strategy?

Since we talked last 18 months ago, we have more than doubled the folks that we have in R&D. As the largest company in the health system-focused virtual care market, we are committed to leading and developing the best technology. But as I mentioned, there’s a lot happening out there. That’s organic, the things that we’re doing within AvaSure where we are spending time and investing.

I mentioned that we completely opened up our platform, and anything our customers want to integrate, we have a standard API for that. We’re going to continue to build a greater number of partners that are pre-integrated and pre-packaged for the benefit of our customers, or if there’s anything they want to integrate, there’s a standard way of doing it.

When you get to M&A, any time that we can accelerate accelerate the strategy and gain team members who wake up every morning and have the same mission -driven passion that we do for improving the environment for care teams and patient safety, then we are really interested in doing that.

Ouva was a great example. Our AI at the time was focused on patient safety. Ouva added additional patient safety modules and modules that support operational elements, such as patient flow. Is a room ready to be leveraged by a patient? They had staff rounding. It was a natural fit where we gained the research that they had done within hospitals, the technology, and a team. That allows us to go faster, be better, and deliver more value for our customers.

Given that we have this large base of 1,200 hospitals, we’re at a great point to bring in emerging, high-value technologies. It’s hard to get things into healthcare, but we can put them on our platform to make them available to our customers.

You spent years as an executive with Hill-Rom, which has been acquired by Baxter, and that company as well as Stryker have extended their reach beyond beds and medical equipment and into digital health and AI. What ambitions do they have for doing more in the patient’s room?

We partner with both of them. They are continuing to build their IT portfolios to best serve their customers. Over time, we’ll probably continue to see more acquisitive activity.

What possibilities does AI add to your offerings?

We as a company are focused on computer vision and noticing more things that are happening in the room. We also have in-flight partnerships around large language models that will be coming to address nursing documentation, but that’s not at our core. That’s an example of where we’ll partner.

Computer vision is in our core. We’ll still partner with others in that space, but computer vision has actually been around for a long time. We see it obviously in the autonomous driving space and it’s been in manufacturing. With machine learning and AI around computer vision, we can already see if a patient is getting out of bed and is at risk at a fall. If you’re a behavioral health patient and you’re moving around the room, you can be at risk of elopement and leaving your room, and we can look for that. 

With Ouva, we picked up technology to know about mobility. If you’re in a hospital and you’re in the bed all the time, that’s bad. You want to be up, be mobile, and prevent bed sores. We can provide data around mobility along with operational elements such as bed management and staff rounding. Those are all things that we have today.

What I’m excited about in the future is that we are quickly adding technology around caregiver harm, which has unfortunately been increasing. We can provide ambient tools for caregivers to leverage if they feel that they are in a position of risk and then alert folks.

We are adding through partnership. There is computer vision technology to start looking at vitals detection, so you can do a better job at spotting patient deterioration and intervening early where you can have better outcomes. Nutrition workflows. Once you have that device in the room, computer vision continues to open up really interesting possibilities. If you had a hospital expert observing in the room all the time, think about how efficiently the activities could be coordinated in that room for the benefit of a patient. In essence, you’re automating that with AI. 

For now and for the foreseeable future, though, we’re going to make sure that we keep a human in the loop. We don’t want to go back to the days of proliferating nuisance alarms. We think that we can continue to improve the effectiveness of the humans in virtual care centers and other settings with the AI, and then over time, provide a level of non-human in the loop, truly autonomous observation for patients who are at lower risk, and also for operational issues.

What will be important to the company over the next few years?

The most important thing to us is that we continue to be the company – we are 15% nurses combined with the technology platform and we we just redid our analytics layer – that combines all of that to make sure that our customers get proven ROI and clinical benefits. That we’re a trusted partner with these technologies that allow health systems to mature as they adopt virtual care and ambient technologies.