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.

HIStalk Interviews Steve Holloway, Managing Director, Signify Research

Steve Holloway is managing director of Signify Research.

Tell me about yourself and your job.

I’m one of the co-founders and managing directors at Signify Research. We are a healthcare technology specialist market intelligence firm. We provide a lot of market data, forecasts, and competitive analysis around the health technology space. 

We have a team of about 40 based here in the United Kingdom with full global coverage in terms of markets. In particular, I’d say specialism around some of the diagnostic and clinical IT areas, diagnostics and life sciences, and a lot of the digital health pieces such as EHRs, PHM, RCM, and the like. We are boutique specialist focused in health tech and we work with big vendors — the GEs, the Philips, and Siemens of the world — as well as big health IT and technology companies to help them shape their strategy for go-to-market in this segment.

What is the state of imaging informatics?

Imaging informatics is a fascinating area in terms of the juxtaposition of bringing new technology to the table and trying to drive technology-enabled change in healthcare systems while also dealing with some of the operational and change management elements at healthcare providers. This involves two main fundamental pushes in imaging informatics over the last few years. One has been enterprise imaging as a strategy for how you consolidate and better manage medical imaging, both in radiology and non-radiology imaging, across healthcare enterprises. There are both IT and software elements to that. Lots of the vendors who are clients with us are trying to push that more consolidated area of focus. 

There is a big care impact and outcome discussion there as well. How do you bring the right information to the right physicians at the right time in the care pathway? We spend a lot of time there. We’re also doing lot of work around how AI is coming into that space. You may have seen the most recent FDA update this morning or yesterday around the number of  AI regulated tools. Radiology is leading the way — I think it’s about three-quarters of approvals that are radiology based. We are learning from that transition. It is something that we have been capturing from the formation of Signify back in 2016.

AI in imaging has been one of the areas that we are closely tracking in terms of market adoption. Some interesting lessons are coming out of that around not being too early in the market. Also, understanding that once you’ve got regulatory clearance, how do you bring that to physicians, how do you build enough evidence for reimbursement, and can you prove the real return on investment for healthcare providers? There’s a fascinating debate going on about how to accelerate that moving forward. We are just getting into the interesting phase of the market, where the initial hurdles are overcome and now we’re getting into how to actually execute on this.

We’ve seen some companies get CMS approval for providers to bill separately for the use of their diagnostic hardware and algorithms. How important is that?

You need to divide the market into two. There’s a lot of AI investment and new products coming to market from established players, the big industrial companies that are reacting to this. With the new slice walls in CT imaging, the AI reconstruction is now seen as one of those critical R&D features that you need to sell more systems. In that sense, there’s less worry about reimbursement. It’s more about defensibility of their core business.

But on the other side, there’s obviously this whole gamut of new vendors and new disruptors coming into play, generally backed by private equity or venture capital money, who are looking how quickly they can enter the market and make a tangible difference. They have multiple stages to get through. There’s building the evidence to convince regulators to approve you to sell. 

Certainly during COVID and the kind of boom of money that we saw coming into the segment, many of those probably not particularly well informed investors were expecting that once the product is available in the market, suddenly it would sell. But I think actually what we’re seeing now is that reimbursement is very much the gold standard, particularly for any diagnostic or clinical decision support tools. You have to prove the case to payers as well that there is a clear return on investment. There have been a couple of very clear use cases in imaging that are the gold standard around that.

Two use cases in particular. If you look at what HeartFlow has done with 4D FFR, it removes a step and cost from the care pathway, but at the same time proves benefit in terms of care outcomes. They did an extensive study that was released I think late last year called the FISH&CHIPS study – which, with my British background, I approve of – where they could  show not just an improvement in outcomes for the patients within a specific cohort that they were targeting, but also in all-cause mortality improvement, which for payers is super critical in seeing that evidence base in the real world.

The other piece that’s become apparent with a lot of focus in the US is stroke triage tools. Actually being able to improve care decisions in terms of stroke pathways, because obviously stroke is a condition that requires quick intervention, and minutes instead of hours makes a big difference in terms of patient recovery. Providers have seen the benefit of some of these AI-enabled stroke tools to make those care decisions more quickly and to provide a definite benefit for care outcomes.

We’ve seen that from companies like RapidAI, Viz.ai, and now Brainomix starting to prove that point at scale in multiple markets. We are seeing other segments looking at what these forerunners have  proven what you can do with AI adoption and the proof point. We need to try and replicate that in our own segment. We have a few  good proof points and the question is how to expand that out into multifaceted solutions.

Many of the imaging vendors are large, multinational corporations, while AI companies are often startups that came from university work. Will the big companies partner with them and perhaps eventually acquire them, or will they develop their own capabilities?

It’s a bit of a free for fall at the moment in terms of market testing around what will work. You also have  a third category there of AI orchestration platforms, and those are both independent and from the imaging vendors. How do customers want to use AI and how closely and deeply do they want to integrate it into their existing systems and care pathways?  

From a business point of view, most of the major imaging vendors have been holding off in terms of aggressive M&A activity. They might have, in a few selective areas, made some early acquisitions where it’s incumbent on their core business that they seem to be innovating, or they’ve already identified the need and it bundles in with their strategy.

But for the most part, the 250-plus startup AI vendors that we see in the imaging informatics space have a waiting period for them to mature to a point where they’ve made their proof in the market. They’re getting towards either reimbursement or at least becoming a more consolidated offering in a given care area. Certainly over the last few years in a more challenging funding environment, we’re expecting that some of the big imaging technology firms will be starting to make acquisitions or at least partnering over the next 12 to 24 months. We will start to see more peer-to-peer M &A, but also acquisition of some of the category leaders into large industrials over the next probably two to four years as well.

The US interest seems strongest in ambient documentation, telehealth, and remote patient monitoring. Is there a global market for those technologies?

There absolutely is. The approach to commercialization and the approach to how you bring these technologies to market differs internationally versus the US. The US is very much regulation-first in terms of the FDA. That’s seen as a big hurdle to overcome because there is generally a higher level of scrutiny and jumping through hoops from a regulatory point of view to get to market first. But then driven by more of a commercial mindset around return on investment, operational and efficiency costs, and then a care outcome benefit. 

You see almost the inverse in many of the international markets that we deal with. It’s blended by how they are funded from a payer basis, but probably the highlights in where adoption of AI tools has been quick is where, as here in the UK, you have had national programs and investment around particular use cases. We’ve just closed out a 21 million pound funding investment around improving and using AI tools to support chest X ray screening. They’ve just awarded a number of contracts across the UK to a cohort of vendors that will drive a change in a particular care pathway. You’re seeing the same emerging now in the Middle East, breast screening in the Netherlands, or Australia adopting these tools. Those markets have more of a public payer piece, so they are looking whether there an evidence base here from a care outcome point of view, and if there is a workforce resource benefit along the way, then fantastic. But they tend to make decisions less on a commercial for-profit basis and more around the outcomes piece.

Getting into the market in those segments is easier from a regulatory point of view because international regulation pieces aren’t as stringent as you see in the FDA. But at the same time, the route to access some of the procurement frameworks, such as the NHS, can be very competitive and very difficult. Same initially in the tendering piece there, same in Australia. with its regional tendering infrastructure. That’s been a challenge in why you maybe haven’t seen quite the same in terms of commercial market adoption so far in these markets. It’s been a little more lumpy, purely because you’re tied to how quickly these procurement frameworks and these more bureaucratic healthcare system payer models can bring innovation on board. Typically that’s a bit slower than the for-profit sector.

In for-profit markets in international, which generally are a smaller segment of the market overall, we are seeing quite a lot of interest and traction.Teleradiology is a great example of that, where there’s a huge amount of investment at the moment going into bringing AI tools – diagnostic, clinical, and operational – to support winning more share of the radiology reading market overall.

You’re seeing the private market in international markets still driving faster than some of the public markets, but there’s a there’s a Catch-22. When it comes to big scale, it’s going to be those national tenders or those big public bodies that make those decisions on investment in the mid to long term. We are starting to see the market gear up for that more, but obviously you are dependent on you big public bodies making decisions, which could take a very long time.

Many of the market’s high flyers from 2020 and 2021 have taken a hard fall, especially those that rushed to go public via the SPAC route. We saw some significant companies shut down completely, such as Babylon Health and Olive. What are the lessons learned?

I hate to say that we have seen this before, but we have. If you go back into the late 2000s, there was obviously a surge in new software and technology, and a lot of that hype never really materialized. We’ve seen the same again with Theranos and the like overpromising and under-delivering. Grail most recently was prominent on the diagnostic side. Health tech can be littered with some of these hyped solutions that fail to deliver.

One lesson learned is that investors are now looking more than the scrutiny around break even, but also understanding the wider picture of how technology is brought into healthcare systems and how you become entrenched with customers and actually solve their underlying problems. Too many of those companies that we’ve listed went in with a very bold vision. Throw IBM Watson into this as well, making big claims and then failing to deliver overall. Investors are wise to that now. 

Because there was such availability of capital liquidity during the period of COVID, they had to put the money somewhere, so they were willing to take a lot more risks. Now we’re in a phase where the cost of debt is higher, although it’s coming down. There is considerably more scrutiny going into, have we really looked at the timeline for adoption here? We know that tech is hard. Have we really looked at how you get customer entrenchment? What’s the land and expand model here? 

Even beyond that, bringing technology to market is one thing, but healthcare is an area where market education is hugely key. It’s probably the most overlooked aspect in bringing health tech innovation into a market,customer education and market education of what you’re bringing to the table. In over 15 years of doing this, I’ve seen examples of companies who’ve brought innovation into the market super successfully, and they have done that by investing a huge amount in customer and market education as opposed to pitching to investors, raising loads of money, and then going to talk to customers and finding out it’s not really what they need. That customer proof point is super critical and often overlooked. 

We ado a little bit of work on that in supporting some of our clients around market education and understanding the forward-looking directional shifts in healthcare technology around AI, generative AI, and real-world data and the potential for precision diagnosis. All these pieces need to be well defined and understood for healthcare providers stakeholders or payer stakeholders to commit to them longer term, otherwise technology is just seen as another shiny thing to add to the to-do list. The change post-COVID is realizing that resources are limited, and therefore you have to be selective of when you’re bringing technology in, making sure that investment is going to move the needle in solving operational, resource, care outcomes, and improving the overall patient experience.

That has resonated far more than five to seven years ago, where it was OK that “this the new, cutting edge technology, and therefore we need to have it.” That balance has shifted back to pragmatism, particularly with some of the budget challenges and resource challenges out there. That’s a good thing for the market. We will weed out some of those that were founded on PowerPoint rather than good customer feedback and understanding the customer and healthcare provider challenge. It’s a really interesting rebalancing, but we’re seeing that resonating through a lot of the business investment case

HIStalk Interviews Ajay Kapare, President, Ellkay

Ajay Kapare, MBA is president and chief strategy officer of Ellkay.

Tell me about yourself and the company.

I’ve been with Ellkay for six and a half years. Ellkay is an interoperability solution provider company. We are in five segments of healthcare.

We are in ambulatory, where we do data migration, conversion, and clinical and financial archiving. We are also in hospitals, where we are an enterprise data management partner. We primarily decommission legacy applications. We provide an archive solution. We offer an interoperability solution called LKOpera to health systems. We are also in the lab segment, which is where we started our business, where we primarily do LIS to EMR integration and also order and result portals. LKOrbit is our lab platform. Close to 700 clinical labs use Ellkay.  Our fourth segment is providing interoperability for vendors. We do any integration that is needed with an EMR, getting the data out of the EMR or pushing the data into the EMR. We’ve been growing in this segment strongly. Finally, we offer an interoperability solution and clinical data exchange solution for the payer market.

We have been growing consistently the last six years and we have nearly 700 employees globally. In today’s market, few companies can say that they have been growing consistently year over year. Our customers and employees are our biggest assets. Customer-first and employee-first have always been our focus.

What business impact have you seen from TEFCA and QHINs?

We are proud to be participating in TEFCA through our work with CommonWell and achieving QHIN designation for the CommonWell 2.0 platform. TEFCA provides guidance for the secure exchange of health information regardless of the location of care. While organizations have been working to achieve this mission independently of each other for quite some time, this framework gives us all a goal to strive for. CommonWell, with Ellkay’s technology, is one of the seven QHINs.

What interoperability requests do you get most often?

More than 70% of hospitals are struggling financially. We are working with those that want to improve their efficiency and reduce costs, working with our interop solutions, LKOpera, or even decommissioning legacy applications that are sitting out there. We give them great ROI in having all that data for the informatics people and clinicians to use through LKArchive.

We see a lot of interest in FHIR. Hospitals, health plans, and vendors are all adopting FHIR within their interoperability arms. With this adoption, we also see the ease of data connectivity and exchange based on standards-based formats that allow the organization to communicate more efficiently and effectively. At Ellkay, we are continually evolving ahead of the industry to be able to accommodate all these standard methodologies and to integrate systems. We are assisting many organizations with transforming data to FHIR resources if that is not configured within their own system.

We feel strongly about our work with CommonWell and implementing the core functionality to their new platform, which is in production, including TEFCA, and all the work around that.

Has AI changed the demand for interoperability or given the company more capability?

The term AI is used everywhere. In the last few years, almost $5 billion in funding has been given to digital startups that are mostly focused on AI. There has been some confusion around exactly what AI is. Even someone who is doing screen scraping will call that AI.

As things have changed for us at Ellkay, we have been working as a true data management partner. Our experience of 20-plus years with healthcare data and data sources is unparalleled. We have almost 60,000 interfaces with different systems throughout the healthcare IT ecosystem.

As healthcare AI initiatives rely heavily on quality data, Ellkay has been laying this foundation for years. You can’t offer new AI technology without good access to quality data. We provide data integrity and data quality expertise to our client partners. We’re also helping them identify the best value-add use cases for the data and guiding them through the noise as they embark on their AI/ML journeys.

How does Ellkay address marketing differently given your strong background in it?

Marketing has always been my first love. Ellkay does strategic marketing. We truly believe that passion, action, and noble intention creates progress. We have never been a very aggressive marketer. We have always been a strategic marketer.

Our virtual user group meeting is August 13 to August 15. Last year we had more than 1,000 attendees — our strategic partners, people from the industry, and prospects. We opened it up to everyone. We had more than 50 speakers. The focus wasn’t Ellkay products, but rather what the trends are in the industry and what changes are happening. Post Meaningful Use and post COVID, what new challenges are health systems, the clinical lab, the ambulatory market, health plans, and payers going through? What challenges are vendors or vendor partners going through? We bring speakers who focus on those areas. When we’re at trade shows, you will see in our booth that our people are always happy. They smile and genuinely want to help.

We can do a great job if there is a market problem that we can solve as a true strategic partner, as we listen more and do focus groups. Our marketing is our voice. It tells the world who we are and what we believe in. It works well and resonates with people. We are true to the core, and whatever we say, we actually mean it.

How do you value collaboration and personal industry relationships?

Our core competencies as a company have always been innovation, execution, agility, and relationships. Relationships play an important role for us. You have to listen to your customers. You have to understand their needs and challenges. When I’m meeting a CIO, a lab director, or even a vendor CTO, I listen to understand their challenges. As a company, we take a customer-first approach and help solve their problems.

We like to keep our head down, ignore the noise around us, stay focused, and keep on doing the same things again and again, repeating the same formula. It’s a process. It’s a journey. Focusing on the things that we can do well has always paid off for us.

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

We want to be a trusted enterprise data partner. We want to be the true partner who can help organizations with their problems, whether it’s a new EMR journey, challenges within their interop needs, or challenges within their lab network. We want to be that true partner, and I’m going to keep repeating this, true enterprise data management partner.

Our future has always been meeting our clients where they are, but also going where they want us to go with them. We will continue to support our client partners by helping them manage their data needs and interop needs, but also by being a thought leader and consultative partner.

A lot of health systems want to do a rationalization exercise around applications that are sitting out there on vulnerable servers. We can do the entire process: true archiving data integrity and analytics based on the type of data and what operational, financial, or clinical needs make sense. Healthcare data is powerful and we should be doing more with it as an industry.

We have some good partners helping us. We are also working towards different growth. We’re looking at international growth. We are looking at what we can do on the data and life sciences side. It’s an exciting time to be at Ellkay.

HIStalk Interviews Vivek Swaminathan, CEO, Cardamom Health

Vivek Swaminathan is CEO of Cardamom Health.

Tell me about yourself and the company.

I like to think of myself as a technical generalist. My education is in electrical and computer engineering and business, but I’ve been in healthcare IT for 15 years and IT overall for over 20, some of that in manufacturing. I’ve been in leadership roles for 15 years and managed nearly every business functions that businesses typically have. Across all of that, I just love working with people and technology. I continue to be fascinated by both, and everything I’ve done has been with that in mind and the idea of trying to do something good and helpful for the world.

I started Cardamon knowing that we would be a little bit different than most businesses, but we had learnings and experiences that we wanted to apply. For example, we often see data analytics, applications, and operations in silos. I’m not saying that they don’t come together necessarily in certain situations, but they’re often not as collaborative as we would like them to be.

For the last 20-something years, we’ve had a huge focus on getting data in, whether it’s implementing a new system, looking at workflow, and doing optimization. But there’s been a lot of struggle to get that information out at the right time, make sure it’s actionable, and all those things that can make an impact. Meanwhile, I’ve watched consulting firms continue to focus on billable hours. Even if they do different things or try to come up with new models, it’s been about that margin spread per hour of billable work. 

We wanted to do something a little differently. We are focused very much on team. We have a team that has data analytics and application experts who want those groups to work together so that we can focus on outcomes. That aligns incentives with our clients. You don’t have this situation where our consultants and our company want the most available hours possible, but the health system or the payer wants the fewest. Instead we focus on the results. What can we do together? What can we make contractual commitments around to get those results for our customers? That means there’s a variety of things that we do, from advisory or specific AI solutions to keeping the lights on and application management services. Our goal is to partner with our customers and find ways to make their lives easier and impact their results.

We focus on two areas. We want to enable the best outcomes for healthcare by maximizing the value of data and technology. The other is for our community. We want to foster an inclusive economy by growing a great, diverse team, but making sure that it also includes people who are overlooked or aren’t often given a chance. That’s how we’ve built this company.

How do you differentiate the company from other consulting firms?

It can be challenging to differentiate at times, often because the health systems that we work with have this tendency to think about staffing. They are used to picking a single person and employing them, or picking them and managing them, and they do progress reports for me. It can be challenging to work with them and find good ways to show value.

The way that we try to differentiate is to say, let’s focus on what it is that we’re trying to do and we can commit to those results. Often it’s at a fixed price instead of continually having hours grow. Often it’s the more complex areas, where you have to work across groups so that we can bring those different experts together. It might be an operational goal or a strategy. It might also just be that you have to work on something, but you don’t already know what your solution is or exactly how you want to approach it. Sometimes that’s how a traditional consultancy might come into play. Here’s this exact thing that I want you to work on. But we’re often trying to work on some of those more complex things, or those strategic initiatives, or the opposite, which is, “Just let me keep the lights on for you while you go do that.”  

How is starting and running a business different from your previous roles with Epic and Nordic?

I will say that it is not for the faint of heart. It has been fun for sure. There have been a ton of learnings. I thought that having been through a lot of different roles that I understood the wide array of things that could happen in any given day in any given hour as you jump from one meeting to another or one subject to another. But it’s exponentially more dramatic when you’re in pure startup mode and you’re jumping from dealing with some insurance issue to then helping a customer and then working on something financial in your cash flow.

It’s kind of all over the place, which has been invigorating because I love variety and change, and I find it exciting. But it’s challenging and can be nerve-wracking at times as you have to think about cash flow every day. I’m not the type of person who focuses a lot on money a lot, and every day you have to think about that next deal in a more substantive way than when you’re already a $50 million company.  It has been a wild ride, but I have fully enjoyed it.

When investors are involved, the focus is often scaling the business up. Is that harder to do with a services business?

I’m not sure that it’s necessarily harder. It’s definitely different. Having worked for both software companies and service companies and having businesses where you have a little bit of both, you have to approach it differently. With software businesses, you’ve done a lot of the R &D work upfront, and a lot of that money or investment is about getting something created or a proof of concept, things like that. On the services side, there’s this balance where you are focusing on these pre-revenue people, but also sometimes they are partially pre–revenue and they’re partially post–revenue.

The challenges and the conversations when you’re bringing in money about what to do next and how to use it can be challenging. There’s a lot more discussion around how much to raise. I try hard to make sure that we are bringing in good investment, not bad investment, where you make sure that you have the right partners that are aligned to where you’re trying to go. Otherwise, you get forced into situations where they wanted to put more money in and now you have to spend it. Maybe you’re not spending it on the right things, and you’re in this perpetual loop of raising more and raising more and raising more. 

Our goal is to find ways to keep that in check. You can always hire people. It’s not that hard to look out there and say, that person’s great, why not hire them? This perpetual balance or back and forth of saying, this is the time to do it. This is exactly what we’re going to use the funds for so that you can grow in a controlled way, but always be ready to grow quickly. That’s what I look for on the the services side.

What’s it like to run a company like yours in Madison?

It’s especially interesting having grown up here. What the environment is like now is nothing compared to what it used to be. Epic and the other successful organizations around here get credit for it. I feel very supported here in terms of having an ecosystem and an environment in which you can find other people to work with, who can give advice,and who are willing to help each other out.

Historically, there have been fewer opportunities to raise funds here, but HealthX Ventures is a great. They are our partner, so obviously I’m biased, but they’re a great example of a group that is tapped into our community and wants to change that and put more money into organizations here. There are others doing that as well. 

There’s more visibility now in Madison, and there are more people looking here than there ever have been. I certainly have felt that support. But out of all the groups I talk to, by far the most people who are interested in investing or being a part of this are not in Madison.

What are some interesting ways that people are using EHR data?

I see it in your AI updates. There are plenty of cool, interesting things that are happening out there, especially from various software companies or product organizations.  I actually get more excited about the functions that are almost administrative. We have some. We created an LLM that’s focused on the bloat that has been happening around reporting and analytics, and how can you analyze that quickly and look at what’s redundant. What isn’t? Where can you do cleanup?

I’m a little bit of the dork on the support side, where it’s like, “How can we bring down the number of things that we’re managing and supporting? How can we clean it up and then make sure we don’t have so many duplicates and things like that?” I don’t hear as many people talking about it, but I think it’s low-hanging fruit that’s out there that needs to be addressed, and there are multiple versions of that kind of use case.

Searching, of course, is another one. We think about our Google searches or Gemini or whatever it is out there. But there’s a lot of benefit from using some of these things for searching or self-service. I almost think of the analogy to the service desk and a lot of the initiatives in the service desk world around self-service and moving work left and all of those kinds of things. A lot of that be can be done in the AI and data world.

Do you feel an urgency to do something with AI because it’s popular?

It is a strategy. We definitely get a lot of questions about it. Certainly investors are asking questions about it and want to pressure you that way. But customers are very interested in it, and we have had it as a strategy. When we’re focusing on data analytics and applications, there’s no question that’s they are a part of that world. 

However, we’re not trying to be AI product company. We’re not trying to go out there and say, “We’ve done this one thing, and now let’s resell it all over.” Because I think that you have to meet the customer where they are, and customers are at all different levels and they have different early pain points. I think it’s more valuable to have wraparound services and using AI when it makes sense. There are times to use it when it can bring down the people hours so that you can bring down the cost and the time to value. For me, those are no -brainer situations to start using AI and to lump that in with whatever services that you’re using. Similarly, there’s automation and other things that we can do in that respect. 

I don’t feel a strong push or desire to be an AI company, per se. It’s just not who we are or what we’re trying to be. But I definitely think we would be doing ourselves a disservice if AI wasn’t a part of our strategy and how we do business.

How has consulting changed after services moved to remote rather than on site during the pandemic?

There has been a lot of change over the last few years, certainly since COVID. I remember 10 or 15 years ago having conversations with customers about asking for people to be able to have one week remote a month. It was a real challenge to get people to accept that. People didn’t necessarily trust that work could be done remotely. I think we’re past that now. For the most part, people understand that you can do work remotely.

It doesn’t mean all the organizations have changed their decision-making on whether they are allowing for remote work. I also recognize there’s some of that as challenges with having to be registered in multiple states and all those kinds of things, but not everybody has accepted that. However, the vast majority I think have, and what we’ve found is that now you have this national marketplace for people, and there’s even more competition for talent. Certain organizations in certain parts of the country have more money and are able to command or pay for the best talent, and it can become challenging for people. It has put a magnifying glass in some of these things that have been around for a while, and now you’ve got more competition for talent, more organizations that are just struggling.

We have customers we work with that have six or seven open positions on one team, let alone across a larger group of IT, and they’re just not able to hire or keep people. That continues to create opportunity for us because we can be helpful to our help systems by having this team for them. It also allows them to maybe hire or get work not to their maximum amount of capacity they need during their peak times, but maybe bring somebody else like us in just to make sure the minimums are covered, and then work with others to scale up and scale down as needed. More and more organizations are opening up to that idea, and nearly everybody I talk to has bought into the concept, but I haven’t necessarily seen everybody be able to actually get it through their processes and make good on it. We’re in an in-between phase right now, but I think that’s where the industry’s going.

What Epic-related work is popular?

New applications continue to be an area of interest. Things like Payer Platform, which has become a bigger thing, especially with small payers or health plans. Part of why we’re working in this data and analytics space is that Epic did a lot to improve their toolset and add functionality in the past five or 10 years, and nearly every health system we talk to says they know that they are not fully utilizing them. Most aren’t there even things like self-service, where they know they can use Slicer Dicer to offer more real-time reports for end users. So a lot of what we’re seeing, and I don’t know that I’d call it optimization, is that if you already own Epic, let’s utilize it to its full extent. That’s the biggest part. There are other things like Cheers when you’re looking at patient experience and campaigns that people are excited about as well.

What do you see as important for the company’s strategy in the next handful of years?

Certainly being an early stage company, we have to think about financials and making sure that we are self–sustaining. We aren’t trying to be the type of organization that has financial backing that then is always raising capital again and again and again. We need to make sure that we are always in a good spot there. As time progresses, we will continue to improve there and be able to make the right investments for our customers so that we are ahead of the game and ready as they need us, which gets to the customer side. We want to make sure that we are making positive lasting impact for them, applying learnings. Hopefully we’re the top partner for many of our health systems that we’re working with. I certainly hope that people are thinking about this approach and are trying this data and analytics and applications together concept, as we are kind of the glue between it, we’re doing managed services for them, and they are seeing the value so that they can focus on their strategic initiatives.

The last thing, and it’s super important to us, is making sure that our team and our culture continue to grow and thrive. We have to bring the right people on board. That’s always a focus for us. It takes work always to have a great culture, and we’re going to do that. We are never going to skimp on that. Three, four years from now, we’re going to be utilizing those economies of scale, the larger team, to be able to do more for our customers in a way that just makes life easier for them.

I challenge myself all the time with this. Let’s all keep learning. Let’s embrace change. I’m a big believer in incremental improvement. Let’s all find ways to make that incremental improvement to slowly move in the direction that we need to go. Obviously, we need to keep people at the center of all this. Let’s not forget that. Let’s not forget our patients that are out there. Let’s not forget our own staffs. Let’s not forget those people that we interact with, whether they’re partners or vendors or whomever else. Above everything else, if we keep people at the center and we keep challenging ourselves to improve, we are going to make tremendous progress in healthcare. So thank you to everyone who is already doing that.

HIStalk Interviews Manny Krakaris, CEO, Augmedix

Manny Krakaris, MBA is president and CEO of Augmedix. 

Tell me about yourself and the company.

I spent the first 12 years of my career in banking. I then made the transition to industry because I wanted to get more of a hands-on experience in business. I’ve been a serial CEO, COO, and CFO of a variety of technology companies in semiconductors, solar, enterprise software, and SaaS. I came to Augmedix via the board. I had previously worked with two of the board members who were representatives of VC firms whose portfolio companies I had worked for. I had just sold my previous company.

I was intrigued by the opportunity. My doctor was a customer well before I met with the board, and she just loved the service. She had told me in no uncertain terms that this had changed her life. I found that intriguing and compelling. When I did a little bit more homework, I came to realize that this was a pervasive problem. Having been new to healthcare, I had no idea that this was a problem in the first place, but it was pervasive and huge. I felt that this is an area where I could contribute, given my background, to help bring a little bit more efficiency into the healthcare sector.

How did the pending acquisition of Augmedix by Commure happen?

We share a common customer, HCA. We provide different services to HCA. HCA gently encouraged us to start talking about how we might be able to stitch together a more comprehensive suite of solutions that addresses a wider swath of the patient journey when it comes to healthcare. The more we talked, the more interesting it became. It ultimately culminated in Commure making the offer to acquire us last month.

Commure had announced its own free ambient scribing solution three months before the acquisition announcement. How does that fit with its strategy?

They did have that offer out there and they still do. The idea is that by offering a platform with a whole suite of products, you can bundle things so that a specific offering can be made available at a seemingly low price or even free in some cases. I don’t think Commure is the first to come up with that concept. Microsoft has been pursuing that strategy for forever, it seems, and quite successfully. In our case, they have an ambient AI scribe product, but it caters to a different care setting than the ones that we focus on, so they are quite complementary. Down the road, will we share similar back ends? Probably, but time will tell.

How do you differentiate your product from the several competing ones?

At last count, I think there are 42 companies that are purporting to be able to generate a note using large language models without any human intervention. The reality is that you can create a draft medical note from the use of automatic speech recognition to convert an audio recording into a transcript, and then large language models take that transcript and convert that into a structured medical note. But the structured medical note that comes out of the back end is a rough draft that requires human intervention to complete it, to edit it, and to make sure that there are no hallucinations in it. The state of the technology is not perfect yet.

What differentiates us from the vast majority of those companies is that we approach this problem organically. We pioneered the whole concept of ambient medical documentation 11 years ago, when no one had ever heard of it. It was revolutionary to basically tell the industry, look, we can repurpose the conversation that occurs between a doctor and a patient and use that as the primary input source to create a medical note. What technology has helped us do in the last couple of years is automate that last step using large language models. If you simply try to modify the technology to this particular use case, you’re won’t get good quality output.

We understand clinician workflows better than pretty much anybody, with a possible exception of one company. We also understand the differences of clinicians’ needs based on care setting, specialty, and the complexity of the encounter. We incorporate that into the portfolio of solutions that we offer today. One size fits all does not work in healthcare.

How important is being able to complete the note quickly, ideally just before the visit ends?

Obviously speed is important. You don’t want to have your customer waiting for minutes or hours for their medical note, because they need to move on to the next patient. For the self -serve products that are fully AI capable, you want to be able to get that draft note to the clinician within a half a minute or so.  Several players have been able to reach that milestone.

Will low switching costs encourage customers to change vendors?

Switching costs with software of this type, which is downloadable application from Google Marketplace or the App Store, are going to become less significant than they were in the past. It all depends on how deeply integrated the application becomes in the clinician’s workflow.

For independent practices, the degree to which the application is integrated in the workflow is pretty low. I would imagine that for that segment of the market, switching costs are going to be insignificant. But for the enterprise, there are significant points of integration with the EMRs, RCM, and patient intake that would make switching costs much more prohibitive for the incumbent to have a greater moat established around their business.

How does the ability to take action from the user’s voice commands overlap with ambient documentation?

They’re pretty much the same thing. Ambient is all about voice. It’s taking the voice recording between a doctor and a patient and using that to generate a medical note. Voice commands, in terms of requesting data from different parts of a healthcare system, are just an extension of the ambient technology. I think that is going to become more and more prevalent. It’s already pretty pervasive in some healthcare systems. I don’t see that reversing. That’s a big efficiency gain for the healthcare industry.

Ambient documentation seems to have higher physician acceptance than most technologies. What is the rationale of those who choose not to use it?

I think we have to stratify the market, which is true of any industry, not just healthcare. When you introduce new technology, you’re going to have some enthusiastic early adopters who want to see change and want to help shape that change. That’s what we’re seeing today in healthcare. The preponderance of users of self-serve AI tools today, whether they are our customers or customers of our competitors, are for the most part early adopters. They are willing to put up with some imperfections in the technology and provide input to make that technology better.

For mass adoption to occur, you need to remove any kind of friction points or imperfections in the technology. I think we’re going to see more and more of that towards the end of this year and certainly in 2025 as the technology matures a little more. It’s not quite there yet, but it’s getting there.

Is it hard to make ambient documentation work as well for specialists and nurses as it does for primary care physicians?

The technology is only as good as the input that you put into training it when it comes to large language models. GPT-4 is a very powerful general purpose tool. If you prompt it with a general question such as “create a structured medical note in these four different segments based on this transcript,” it will do that for you. It will be OK, but not great.

However, if you start asking it more refined questions — for example, if you do what we do with proprietary models that identify in the transcript the key elements of that transcript that you believe are relevant to the medical note — and then you ask it specific questions for each one of those elements, you narrow the variables that the LLM has to deal with to generate a response. The fewer variables you ask the model to work with, the more accurate your output is going to be. That’s what we do. We ask very specific questions of each of the key medical elements that we identify in the transcript in order to optimize accuracy.

Beyond reducing after-work chart completion, does ambient documentation reduce the cognitive load of physicians who otherwise would need to listen and type at the same time or try to recall parts of the conversation to create documentation after the fact?

Yes. We conducted a study with one of our largest customers. It was a pretty broad study that included primary care physicians and a variety of specialists, well over 100 clinicians whom we studied over a year.

We discovered that for primary care physicians, the biggest source of improvement in their WRVUs — their work relative value units, which is a standard measure of performance of a physician — did not come from increased patient throughput. Rather it came from higher capture rates, which then resulted in higher reimbursement.

It’s not intuitive at first, but if clinicians have to try to remember everything that they did during an encounter when they subsequently do the medical note, several things may slip through the cracks. That is, in fact, what has happened, in our study at least. Those slippages, those things that were omitted, represented about 80% of the lift, and the lift was significant. You can add value beyond increasing patient throughput or reducing pajama time.

What is the near-term future for using AI in healthcare?

AI has the capacity to learn quickly. The rate at which it learns really depends on the rate at which you can feed it relevant data. It will be incumbent on healthcare systems to ensure that the data that their vendors are using to train their models is representative of the patient population of that particular healthcare enterprise. It’s not good enough, and in fact is  counterproductive in many ways, to use generalized data from the general population. If you’re trying to cater to a regional healthcare network that caters mostly to foreign-speaking people or people of a certain ethnicity who are not represented equally within the general population, that will skew how the model interprets certain information. It’s important to tailor the data that you use to train your models to the patient population that your customers are serving.

Second, as you train the models, you can actually help the model mimic the preferences of the individual clinician, looking at what the clinician does from an editing perspective after the draft note is delivered to the clinician. Take those edits that the clinician makes to what the technology generated and put that back into your training data. That will generate a note that better reflects the preferences and stylistic preferences of the doctor. That’s going to be welcomed by many doctors, because they have their own unique ways of documenting their interactions with patients. AI has the ability to to learn from that as long as we can get that that feedback and incorporate that into the training models.

What does the post-acquisition future of the company look like?

This is my first foray in healthcare, so I come into this with a naive perspective, but if you follow the patient journey, it has many steps. Each one seems to be provided by a different entity that is providing a very specific task. If you look at it holistically, to go from patient intake to final reimbursement, there are way too many disjointed steps in between.

What I think the healthcare industry could benefit from greatly, which is lacking so far, is compressing as many of those steps as possible by integrating them on a singular platform that seamlessly transfers information from one functional area to another to another to avoid what happens today, which is a lot of manual intervention to clean up imperfect input from the preceding functional step in that journey. That introduces a lot of cost in the system. That’s something that the healthcare industry really can no longer afford to do. Commure’s vision is to be the first in the industry to be able to do that. I think we play a central role in that strategy.

The healthcare industry is intriguing. It’s massive. There are a lot of challenges in front of us, but I think the people that run the big hospital systems, healthcare networks, and IDNs, are of the mindset today that doing the same thing is not going to yield the kind of results they need to generate in order to be able to continue to deliver healthcare to a growing and aging patient population. They are a lot more willing today than they were six years ago, when I got into this industry, to explore these new opportunities and new technologies. I find that very encouraging.

HIStalk Interviews David Lareau, CEO, Medicomp Systems

David Lareau is CEO of Medicomp Systems.

Tell me about yourself and the company.

I’ve been the CEO of Medicomp for about 15 years. I originally came from a large network background and then started and owned a billing company. I met Peter Goltra, who founded Medicomp in 1978, in the 1990s.

We’re actually a year older than Epic. Epic does many things and Medicomp does one thing, and that is to build a clinical data engine. The Quippe Clinical Knowledge Graph works and thinks the way that clinicians do, so that they can use it at the point of care. It has almost half a million clinical data concepts across all domains. We have worked with clinicians for more than 40 years so that when you are thinking about a specific problem, what are the things that you want to see in all the clinical domains — symptoms, history, exam, tests, diagnosis, therapies, comorbidities, sequelae – so that the clinician can consider any condition or diagnosis and immediately see all of the information that their peers and colleagues over the years have told us they would want to see.

Those half a million clinical data points are both computable — because it has a common data model underneath it — and human readable at the point of care. It has over 10 million mappings to the standard terminologies and accommodates all the downstream processes like CQMs, adequate documentation for HCCs, E&Ms, diagnostic view of the record, and things like care management protocols for nurses, physicians, and affiliated health professionals. We’re starting to get into home care.

You’ll start to see over the next six to nine months some of the significant vendors coming out with a hybrid model that uses large language models and ambient listening to capture information, but then uses our Clinical Knowledge Graph to process it, present it to the clinician, and allow them to navigate it and trust it. It’s evidence-based. It’s linked to sources. 

Once you’ve removed the burden of documentation, how do you accommodate the way a clinician thinks and works in supporting all of the requirements that are now being piled on in terms of HTI-1 and now HTI-2, CQMs, et cetera?  We are pretty pumped about the next two or three years and the way the industry will develop from transaction based to clinical care from a data-driven perspective.

Strong point-of-care technology use cases involve surfacing relevant EHR information and connecting the clinician to medical evidence. How will physicians benefit?

It will help with the acquisition of information with the patient’s involvement, what the patient says and then getting that into the record in some form. Ambient listening stuff is doing it in text. Large language models are good at synonymy and summarizing information. But the clinicians at the point of care are some of the most highly educated and trained knowledge workers on the planet. Most of the time, they know what they want to see. They just don’t like looking for it in the record.

The hybrid model that I was talking about a few minutes ago is to remove some of the burden of entry and documentation, perhaps using AI ambient listening, but then giving the physician transparent, citable, and authoritative comfort with what the EHR is giving back to them among all that information that is in this patient’s record – here are the things that I found related to that problem. That’s that Clinical Knowledge Graph that we’ve been building for years. 

Even though the burden of documentation is lightening, the need to find what you need, work on it, and support all those downstream processes quickly, trustworthy, reliable, predictable — that’s where we fit into this whole puzzle that the industry is trying to put together.

Technologists sometimes miss the significant point that physicians don’t need or want automated help for 95% of their patients, who have a relatively small variety of conditions that they treat all day long. Can personalization or customization give physicians what they need rather than what someone else thinks would be helpful?

You have hit on something that we used to say all the time. Tell me what I need to know, when I need to know it, don’t slow me down, and don’t get in my way. If I need help, I’ll ask for it, and it had better come back quickly.

I’ll give you an example. We’re working with a company that is using ambient listening, AI, and large language models to capture documentation. Certified EHRs are required to have a problem list, which is usually in SNOMED or perhaps ICD-10 in older systems. If the clinician is treating a patient who has a known problem, we can use our Clinical Knowledge Graph to tell them what’s in the record that pertains to that problem, symptoms, and history. Give them their standard presentation so they know where to look – they don’t want each encounter to be a new and exciting experience. It’s formatted the way they want. They can find the information that they need that is related to this patient’s problem. 

If there’s a new problem, like the patient has been  having difficulty swallowing, go to the Clinical Knowledge Graph, type in “difficulty swallowing,” and get a list of things and filter the record for that so they can see it. Do it in a format that the clinician has personalized to the way that they practice. Cardiology is looked at something different than an audiologist, for example, or a nurse. There’s customization of presentation, but there’s diagnostically connecting the information, filtering it, and putting it back to them the way they need it when they want it. I’ll call on that knowledge resource when I need to, which as you just said is maybe three to 5% of the time.

You have said that you stopped using the term AI even though Quippe gives the appearance of applying it under the hood.

I was doing a major presentation for a large medical group in Southern California years ago. I showed a differential diagnostic presentation of a complex patient. One of the 200 docs in the auditorium got up, and before he walked out, said, “Why did I go to medical school if you’re going to tell me what you think this patient has? I already knew it before you even started that. We want real intelligence, not artificial intelligence.”

After hearing that a number of times, we said that we aren’t going to talk about that any more. We’re just going to talk about presenting information that works and thinks the way clinicians do, because we have been working with clinicians for over 40 years to build this thing. We took artificial intelligence out of anything that we said, because people found it hard to believe, and physicians particularly found it offensive.

What are the challenges in using technology to reduce physician burnout?

I think having reasonable expectations. If you set the expectation that large language models and artificial intelligence will remove any need to interact with the EHR because EHRs are just a chore and not a tool, you are bound to be disappointed. Approach it as, “What can this technology be used for that lightens my burden and helps to make the EHR a tool, not a task?” One aspect is summarizing the information that is already in the record. It’s starting to do a decent job doing that as opposed to actually entering data in the record. 

If you use the current versions of this technology to enter data in the record, you have to review it, because there’s still a pretty high hallucination rate. It wouldn’t kill you if it was used in an Amazon warehouse and they ship you the wrong product, but if you put a wrong piece of critical information in a medical record, it can have serious consequences. 

Summarizing it for review, great. Specific things that ease the burden not only on providers, but on people who are building solutions for providers. We are using it to reduce the work we have to do. We have 10 million mappings of our half million concepts to the standard vocabularies. That’s a lot of work, a lot of what terminologists would call in-the-trenches grunt work. AI can help reduce the amount of time it takes to find possible matches and then have somebody look at it.

We approach the point of care the same way. Let’s use our engine to filter the stuff coming out of these models, sort of a hybrid model, and make the best use of our evidence-based Clinical Knowledge Graph, along with the output from the large language model. In that hybrid approach, AI is not going to do everything. It will do some things, such as specific point solutions related to a task or process, but it’s not going to completely take care of the patient. Our role in that is giving the clinician a tool that allows them to find what they want, review it, take action on it, and then use AI for the things that it works well for – summarizing a record and looking in it for occurrences of something.

It’s still early in this. You’re going to see a lot of these companies hit the wall when their initial funding runs out. Then you will see some big players succeed and maybe dominate the industry. There will be a couple of new ones, too.

How about technology that addresses burnout in nurses?

We have always thought that in terms of care delivery, a hospital is a high-tech facility that is run by administrators, but operated by nurses. For the actual, on-the-ground patient care, the nurses are the ones who first notice what’s going on with the patient. The nurses are the ones who call in the physician expert when they need to. They are the ones on the front lines.

Holy Name Medical Center in Teaneck, New Jersey — which was on the cover of Newsweek as an epicenter of the initial COVID outbreaks back in April and May of 2020 — put Quippe in during COVID in the emergency department and the critical care units of the hospital, the intensive care units and the cardiac care intensive care units. They noticed that within two weeks, the nurses had more than two hours a day of time freed from documentation, because we had the data points that are needed to support their processes. We had tools that they could use to design what they were doing in accordance with the processes that were already in place. It was just astonishing to us that they were able to do that.

We learned a lot from that, too. We learned the difference between diagnostic care of a patient and coordinated care team care of a patient, because that’s really where nurses operate. They operate as the eyes and ears of the enterprise on the patient, helping to coordinate the care of the whole team. That made us start improving our design processes that people could use with our Clinical Knowledge Graph to accommodate coordination of care among members of a care team, which is now a big topic for HTI-2 coming down the pike in a couple of years. Every time we go into a new environment, we learn what we didn’t know and adapt accordingly.

What are the next steps in interoperability, especially in data quality and interpretation?

Years and years ago, a senator named Ted Stevens from Alaska said, “The internet is nothing but a series of pipes,” and everybody made fun of him. When I read that old quote from him, I thought about interoperability. We now have a governance structure through the QHINs and through TEFCA. We have built the pipes, and the pipes are available. You will be required to send stuff down the pipe. You will be required to receive stuff from the pipe. The challenge will be how you keep from getting overwhelmed by what’s coming down through the pipe. How do you filter it? How do you present it?

You said before that clinicians will tell you that 95% of the time that they know what they need to treat a patient. That same statistic could be applied to that tsunami of information that is coming down as text, codes, pictures, and all kinds of stuff. Filter it so that I can find what I need. We’ve been working with FHIR and other things for about eight or nine years – and now NLP and large language models – to quickly find the information that is needed in that for the particular patient that is being treated. We are excited that the pipes are in place and that the information will start flowing. That gives us a unique opportunity to show what you can do when you have a Clinical Knowledge Graph with 10 million mappings to the standard vocabularies and hundreds of millions of diagnostically connected data points inside an engine. 

It will be interesting to see how the industry responds to this deluge that they are going to get. It’s an exciting time. I think the HIMSS Interoperability Showcase is what, 15 or 20 years old? Finally, it’s real. But it will take some time to iron out the wrinkles to get the exact information that a clinician needs to the point of care so that they can benefit from the content of those pipes.

How will AI affect your products and competitive position?

Our approach is that we are a good solution for the hybrid model that I talked about earlier, for using AI to acquire the information, bring it over, and then allow it to be formatted, filtered and presented. I get a lot of inquiries about using content as training data, partnering with us, acquiring us, or licensing our intellectual property. We are  too busy right now to respond to that, but we see our role — and HTI-1 kind of covers this — as the evidence-based, trusted resource for source information that has been reviewed by clinicians to handle output from large language models and AI.

It’s not clear to me how quickly people are going to believe that AI can do what we do. The people who have looked at our stuff and tried it have said, you guys have something special here. We have a solid, consistent clinical data model underneath it. It’s not just words linked together. We like the opportunity that we have over the next five years.

The big picture is the industry has not yet come to grips with the tools that are needed for an enterprise, or even an individual clinician, to effectively manage chronic conditions like the Hierarchical Condition Categories that Medicare is using for compensation. There’s lots of money and attention flowing into that. If you look at ICD-10-CM diagnoses, about 9,000 to 10 ,000 are relevant and apply to these Hierarchical Condition Categories for value-based payment.  A huge opportunity for us over the next two to three years is that we can review and filter a record to make sure that the documentation is appropriate, is complete, and that product conditions are being identified and effectively managed and adequately documented to pass a Medicare audit.  

Requirements are piling on the industry. HTI-1, HTI-2, TEFCA, CQMs, and quality payment programs. They are all tied to very specific clinical data points, and that’s really our strength. We’re pretty excited about the next three to five years.