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.

HIStalk Interviews Cyrus Bahrassa, CEO, Ashavan

Cyrus Bahrassa is founder and CEO of Ashavan.

Tell me about yourself and the company.

I’m somebody who would not have imagined being here talking to you. When I was a kid, healthcare IT was not on my radar. I’m not sure if anybody really does have it on the radar. I wanted to be a commercial airline pilot. In college, though, I found a passion for education. I thought I would be a teacher and eventually a principal or superintendent. But then a little company called Epic reached out to me in my senior year and said, you probably haven’t heard of us, but you should check us out. I did and I liked it enough to join the company, thinking I would be there just a couple of years. Instead, I stayed for seven, and somehow have been in the industry for my entire career.

Ashavan is a healthcare interoperability consulting company, or at least that’s what I tell people. But truthfully, that’s not the full story. Fundamentally, we are a company that is focused on choices. Our mission is to make the best choice the easiest one, and everything that we are trying to do is in service of that mission. Today, we’re focused on interoperability, and that’s going to be our focus for a while. But the pie-in-the-sky vision is that 50 years from now, we are helping people and businesses make optimal choices in other areas, things like sustainability and money. When we can make it easy to do the right thing, that’s where I would love or Ashavan to play a role.

Are the big non-healthcare companies surprised by the complexity of getting and using healthcare data?

Yes, especially the ones that are newer to healthcare. Maybe they have experience in technology in other ways, but they’re jumping into the healthcare side and saying, why is it so hard and complex and convoluted?  At the end of the day, it feels like a jungle. That’s what we see and hear from our customers. We are helping them carve a path through the jungle and helping them understand that this is the right way to go about this. You will be able to move as efficiently and practically as possible.

That doesn’t mean that it will be easy. It will still be hard. We can’t claim to have magic bullets that make everything push-of-a-button automatic, but at least we can help you move faster and more efficiently and have that certainty and that clarity that you might not have if you didn’t have that guide with you.

What is the incentive for a software vendor or provider to share information?

It’s a hard question to answer, because the incentives probably aren’t as strong as they could be. What I would preach in idealistic fashion is that we have to look at this from the perspective of customer service and doing the right thing for people and for their health. Sharing data and providing greater interoperability is an important piece of that. Do those entities have a vested interest in those things? Probably not, unfortunately. I hate to say that, but the reality is that they may not maximize their individual potential when we’re working in service of that common good. But that is a North Star that we have to have.

Unfortunately, that’s why government plays such a big role in healthcare IT and in interoperability. Sadly, the pace of innovation and interoperability is mostly dictated by the pace of change from the government side. You have USCDI, for example, and that’s a great thing. It allows for a certain floor in terms of API-based interoperability and retrieval of data. But that floor has remained stagnant for a while. It’s been at the Version 1 of USCDI for a few years now, and it won’t be until 2026 that that floor moves up to Version 3. Then it won’t move again until the ONC decides to make that change at some point in the future, which of course is dependent upon the circumstances in the industry, the political circumstances, and what kind of administration is in power. The challenge here is that we are working at the pace of government.

Where does the patient fit in?

The patient plays a huge role. First and foremost, they absolutely have a right to their records. They have a right to obtain records when they have the appropriate authorization for a family member. That is super important and something that has to be enforced strongly. 

I look at it like personal finance. We probably need to teach people to a level of literacy as they are growing up and as they are in young adulthood to help them be better healthcare consumers. More and more states are mandating education around personal finance in middle school and high school. Having individuals be knowledgeable of what their rights are, understanding the importance of having access to their data, and helping them understand the value of that access and that data exchange in practical terms.

When I explain interoperability to folks who don’t really know about it, I talk about smartphones. Imagine that you’re an Android owner, but you want to switch to an IPhone. You love everything about the IPhone, you can’t wait to switch, but then you find out that there’s no way to get all your photos, contacts, and messages pulled over automatically onto your iPhone. At best, you’ll have to manually key in everything, or at worst, you won’t be able to move some stuff at all.

That would be really, really bad interoperability. Thankfully, we don’t have that, but that’s a practical example of the power of data exchange and interoperability. Then, helping someone understand in the context of healthcare why that’s significant. You want to be able to switch your doctor, you’re moving to a new location, or you’re traveling and you need care in a new place. Having the ability to move that data and make things seamless, easy, and powerful is so important.

Apple Health was all the rage when it was announced, even though Google and Microsoft had failed in trying to do something similar. Has the uptake of Apple’s health-related capabilities proven that demand exists for patients to manage or transfer their own record?

There was a moment where personal health record apps had this big shining glow around them and everyone was pretty hyped about their potential. They are important, don’t get me wrong, but it’s this problem in healthcare and interoperability where you can get the data, but then how do you use it? It’s one thing to have it there, but it has to be usable and actionable. 

Allowing patients to pull their data through Apple and through other services is wonderful, but do they have that literacy and empowerment to use it? Do they have the ability to connect it somewhere else so that they can switch to a new provider or switch to a new location and have that data be equally understandable and actionable? 

The ability for these personal health record apps to pull in that data, showcase it, and surface it to the patient is good for them and for their ability to navigate the healthcare ecosystem.  But some folks are not going to pay attention to it as much, especially if they are relatively healthy or their health stays pretty constant and they don’t necessarily think about healthcare very often. Some folks, again, are just not going to have that literacy or that capability to be able to work through that. We have to do things as an industry, as a society, to help them navigate that better, to empower them, and to safeguard them.

My last thought here is that a lot of folks don’t understand what HIPAA truly covers and that some of these digital health applications — unless it’s as a business associate of a covered entity – aren’t subject to the HIPAA requirements. I’m not sure that most people will ever understand that. That means that it’s even more important for us to craft the laws and regulations that provide a suitable level of privacy protection so that the protection of their information is automated, no matter who the holder of it is. Again, this is all about choices and making the right thing the easy thing. If we can update those laws so that your information is protected in all these different situations and apps, that’s better for everyone.

Is the answer to update HIPAA or to implement general privacy protection?

It would be pretty comprehensive. I say that because of a couple of factors. What will prompt some sort of action from Congress, whether it’s in two years or 20 years, is these challenges around social media now also AI and the way that our data is used and monetized. I see that as being a big driver for some sort of action on privacy legislation. 

Unfortunately nowadays, there’s a tendency for Congress to take a long time and then do this big sweeping package when the time presents itself. I can see them getting to this point where privacy legislation is going to happen, and then healthcare and healthcare apps become a component of that larger bill. Like a lot of humans, I’m terrible at predicting the future, so I could very well be wrong and I’m going to be willing to admit that, but that’s what I see.

As someone who has worked both for and with Epic, do you see them as an interoperability friend or foe?

I see them as simply a self-interested player in the market, just like any other entity out there in our industry.

I believe a few things. Epic has a lot to offer when it comes to interoperability. They and Athena are at the forefront in terms of the different options you have and capabilities that you have for integrating with them, whether that’s HL7 interfaces, both FHIR APIs and proprietary APIs, Kit, etc. They have lots of available options that several other EHR vendors cannot claim to have.

At the same time, Epic is guilty of certain practices that are either common in the industry or that are unique to them. The common thing is high fees. I’m a big believer that we have to crack down on the fees and just charge for the cost of interoperability without making it a profit center, but simply a pass-through of the costs.

I also think that we need to address things like exclusive marketplaces and exclusive programs. You have the Epic Vendor Services program and Epic on FHIR, but you also have through Cerner what is now their Oracle Partner Network, which used to be their code program. You have the Athenahealth Marketplace. Similar to the Apple App Store and Play Store, those are the exclusive venues that you must go through to publish an app and use it with the particular EMR. I think that’s wrong. You should be able to have additional marketplaces. You should be able to pull down apps and list apps in multiple places. 

Those are the general things that I would say for Epic. A specific thing that I was concerned about was their Partners and Pals program. I spoke out about this several months ago when it was first announced. To me, that was the wrong move, because it at least implied — and no one ever denied this — that Epic was providing exclusive integration options to certain Partners and Pals that would not be generally available to everyone. I think that’s wrong and anti-competitive. For interoperability, the same capability should be available to all entities at the same time and at the same cost. That’s an important piece, because interoperability goes hand-in hand with competition, with a freer market, with allowing people to have better choices and to minimize the switching costs between those choices.

AI companies are desperate for data and will likely bring their own ideas about interoperability. How will that business need influence the technical side of interoperability?

It will increase the demand for sure. The key challenge is that when we’re talking about healthcare data, it doesn’t all live in just EHRs. We’ve got the ONC’s certified health IT program to ensure that these EHRs have this minimum level of data. Certainly they are a wealthy repository for that, but you’ve got data living in all kinds of other systems, whether it’s an uncertified EHR, a behavioral health system, a system used by a long-term care facility, PACS, and lab systems. It’s his big, hairy beast and the fragmentation problem in healthcare technology is a real challenge in interoperability, because you’ve got data that’s living in all these different places.

With regard to the business side, there will be demand, but the challenge is how you target that demand to the right entities. If you’re a pharma company, you will have to take it one by one in terms of where you want to get that data and get those capabilities to pull that data, because it’s not like there’s one source and one a one-stop shop.

When I explain interoperability to folks and some of the challenges, I talk about Uber. With Uber, you can see a map and a timing for your ride. Why is that possible? It’s because Uber has integrated with Google and their Google Maps functionality to be able to provide that information. Uber only had to integrate with Google and that’s it. They get everything that they might need.

But that’s not the same thing in healthcare. You can’t go to one single place and get everything you need, even as a patient. Our information is in the EMR, but also in the PCP’s EMR, the hospital’s EMR, in the Walgreens where we got our flu shot last year, and in the urgent care. Being able to source the data from all those different places is something that is going to be really challenging, whether you’re a business or a person.

How does Nashville’s innovation and digital health environment compare to that of Silicon Valley, Route 128, and Austin?

I’m biased. I love Nashville. I tell people that it’s the greatest city on earth. I’m sure lots of folks would disagree with me, but it is a wonderful place that I hope lots of people can at least come and visit, if not move to.

In terms of the entrepreneurial scene and the technology scene, it has really flourished. I’ve only been here five years, so I can’t say that I have a perfect window into everything that has gone on. But a lot of people are focused on making Nashville a wonderful place. There’s a lot of positive energy around technology, innovation, and entrepreneurship.  We have a really thriving entrepreneur center, a couple of them actually. We’ve got great programs and accelerators that support these different startups. There are certain people out there who are trying their best to attract investment, attract attention, and build that culture.

We’re a tightknit community in the way that we come together and support each other. I’ve always felt like people are out there willing to help, willing to lend a hand, and meet or introduce you to someone, which I think is really great. That supportive environment has made it a wonderful place to have a business and to live. We’re doing the right things.

It always helps when you have a big name who is drawn to the city, like Oracle. I know there was the announcement about moving the headquarters here. I’m interested to see how that plays out and what it looks like, but even just having that campus here and what they’re doing to build that up and build up the East Bank of Nashville is really special. That drives attention and creates that network effect, because more and more organizations will now take a look at us and say, this is a cool place, we should check it out, we want to be here.

What are the company’s plans for the next few years?

I have to get better as an entrepreneur. That’s the thing that’s top of mind for me. We are three and a half years in. It’s gone well, but I’m still learning. I’m still improving. I probably will be every day of my life. Even right now, I’m trying to figure out how to be a leader and not just a hero. That’s a really important thing on my mind.

In terms of the company, healthcare will always be a focus area, but we definitely want to expand beyond that. Interoperability is a big deal in a lot of industries. You’re talking financial technology, manufacturing, logistics, etc. I was at a conference recently on smart transportation and mobility. There’s a huge need for better interoperability so that the streetlights, stop signs, vehicles, and scooters can all talk to one another. That’s going to be important for a modern transportation infrastructure.

What we want to do at Ashavan is earn a seat at the table in those industries. We want to be a part of bringing about that change and bringing about better interoperability in those areas, because when we can make the best choice the easiest one for those consumers and those companies, we’re going to feel like we’re making a positive contribution to society, and that’s going to be really special.

HIStalk Interviews Trip Hofer, CEO, Redox

Trip Hofer, MBA is CEO of Redox.

Tell me about yourself and the company.

I joined the organization in November of last year. I’ve been in healthcare for approaching 25 years now, and throughout that time, we’ve always talked about the ability to get data easily from one system to another, from A to B. A to B can be from an EMR to an EMR, from a digital health vendor to an EMR, from an EMR to a cloud, or from an ecosystem that has been built specifically in a payer environment. I’ve seen various A to Bs, but throughout my career, what seemed simple verbally and logically got complex and became undoable. That was always frustrating when trying to serve patients better. 

Especially at the time with value-based care, I thought that Redox could be interesting since it has been moving data for 10 years. Redox was primarily focused on enabling digital health vendors to interact with an EMR, to both read and write into and out of an EMR. That is incredibly important for digital health vendors and for the providers who are working with their EMR to have access to other methods for serving a patient.

The company has expanded to not only do that, but also to move data from anywhere, from point A to B. With AI and machine learning, an important need is to get usable data quickly in large volumes safely. We are at a remarkably interesting time for the company and for the industry as a whole.

How do you see interoperability evolving, specifically with FHIR APIs?

It will continue to evolve. It’s top of mind. I was at a health plan a week ago with a bunch of cloud vendors. FHIR usage is proliferating, being used and applied by any healthcare entity. That’s great. You wish it was like, “Just adopt FHIR, it will be easy, and we’ll move forward.” The fundamental challenge with healthcare data, which is unique to any other industry, is that the data is extremely messy and it continues to change. That is a symptom of workflow.

For example, follow a claim from initial generation all the way through adjudication. It goes through a ton of changes. You can call it maturations, but changes or evolutions or whatever the term you want to use through that process. It seems simple, but it gets updated, it could get rejected, more information might need to be added. It is messy. It could include the wrong diagnosis codes or the wrong name. That’s just a claim that flows through, and there’s a lot of discussion on prior authorization.

While the advent of FHIR is really important, getting data from point A to B in healthcare is difficult because it’s messy. FHIR helps with that by having a standard format that is being adopted, but it’s the workflow that makes it so complicated.

How does the company work around that messy data?

I’ve learned that the idea that you can just go buy a piece of software off the shelf and plug it in can be used for the simplest of of tasks. But getting more creative with data, or using it for other purposes — especially with large volumes of data — that’s not enough. We’re a technology company with services. We have people who work with each of our clients to make sure that the integration meets their needs. We apply use cases. What problem are we trying to solve specifically?

The beauty of Redox is that each integration implementation leverages usable technology, meaning that we don’t have to start from scratch. We have over 7,500 connections established across the country that we can leverage. Implementation can be extremely fast. The national plan that I just visited took three months. If you ask any health plan about how long a typical data integration takes, it’s not measured in months, it’s measured in years. We can  get stuff up fast, but we also apply a combination of usable technology and people who know what they’re doing because they live it daily. They help with that integration implementation and ongoing maintenance and monitoring of the technology.

What changes will 21st Century Cures and TEFCA require?

I am a fan of 21st Century Cures and TEFCA. Their general objective is to make it easier for patients to get their information. I don’t know how anyone isn’t a proponent of that. We all want it. I want it as a consumer. I want to be able to get my information as fast as possible during my care journey. It forces organizations to think about how they’re going to make that easily accessible.

The problem with TEFCA is that it’s optional. There are no incentives or penalties for organizations to adhere to TEFCA. You can if you’d like, but you don’t have to. You’ll see adoption without incentives or penalties, but not at the level there would be with a mandate. If there was going to be mandate around it, we would have to carefully think about what that means. How do you ensure that what is written and regulated or mandated is appropriate? If it’s going to be a true game-changer, especially TEFCA, you have to see incentives or penalties and take away the optionality.

We’ve seen controversy over companies using data for non-treatment purposes. How will that evolve?

That’s going to be very interesting. I’ve been following the same cases and situations and the companies that have been impacted by that. These are treatment use cases are flowing through here and ensuring what treatment means. An act like TEFCA or 21st Century Cures can be so good. But other organizations are bad actors in this environment who want to use that data for alternative purposes. You think that this is treatment, so it should be easy, but data has been leveraged for other reasons. 

When you  get into something around payment, that gets even more interesting when it comes to how people might inappropriately leverage that data. That’s the concern. I still think that those use cases should move forward and should get access, but it has to be in a way that ensures that those bad actors or actresses can’t perform the way that they want to, and that’s difficult. That’s really hard. I wouldn’t even have thought on the treatment side that you would have seen what you’ve seen, but I think I was being a little naive. 

People think about these things and figure out ways to exploit them. That’s what we have to be concerned about, especially when we get into the money side of things, beyond treatment use cases that will proliferate. How do you try your best to put measures in place to stop that from happening?

How will AI to affect your business and your customers?

It doesn’t come as any surprise that AI is discussed at every industry conference. When we talk to our clients, AI either comes up or is the focal point of the meeting. I was at one of the large cloud aggregators two weeks ago and their request of us was, we have a lot of tools that can consume information that can do some really interesting things, but we need that information in a way that we can consume it. That’s where we come in as Redox. How can we move data, and large volumes of data, securely?

I want to make sure that those two points aren’t missed. We aren’t talking about moving small amounts of data. These organizations are asking for a large amount of data, billions of transactions. We’re now moving over a billion transactions a month at Redox, and I’m thinking that by the end of the year, we will probably move up to a billion and a half per month. That’s a lot of data, and you must have a platform that can move that data. The platforms of some organizations have just not been able to do that. They can’t handle the data.

OK, you have to be able to handle data, but quickly on top of that, how can you handle it securely? Challenges around security and all the breaches are major concerns. How do you ensure that you have the security? It’s funny that when we get into AI discussions, we typically lead with how we think about moving secure data, and I had organization say that they appreciate that we talk security first because it is so top of mind.

But that’s what we do. We are an enabler. We don’t run the tools at the end of the pipe to take advantage of it. We pride ourselves on providing the data that is necessary to enable those tools. We are enabler of machine learning or of artificial intelligence, and as I continue to remind our team, we are also the enabler of value-based contracting and value-based pricing. Having been in healthcare for so long and seeing fee-for-service not work, we have to move more quickly to value-based arrangements. The only way you do that is to provide good, clean data to expedite that. That is top of mind for us as well.

When it comes to our own company, we actually just sat down and had this conversation, which is funny that you ask. I said to the team, not only how do we use AI, but if AI were to make Redox obsolete, what would that look like? The reality is that there are parts of the ecosystem where we perform — if you think about a pipe or a highway, what that looks like along the journey — where AI is very applicable, but there are other parts where it’s just not, not now at least. 

A lot of that has to do with the manual intervention based upon workflow, things that make AI something that you can’t put into that part of the ecosystem at this point. But we’re constantly looking at that, because we want to make this as efficient and effective for our customers as possible. Wherever we can leverage AI to do that, we will do that. Where it’s not leverageable, we won’t. We are truly trying to enable our end users with usable data, and if AI helps that, we will implement it, period.

Your other job as a venture partner gives you frontline exposure not only to AI, but to what companies and investors are doing and thinking. How would you characterize the health tech investment marketplace?

There’s a couple of things that will probably come as no surprise. The first is the general environment today, which really started last year or maybe a year and a half ago when venture capital money seized up and the spigot stopped flowing. There was a lot of what you would call tourist investment going on in 2022, where people who didn’t really know what they were doing in healthcare were throwing a lot of money into healthcare and into companies. It was great to receive the money if you were one of those organizations, but also now you’re feeling the effect of where it has seized up and you don’t have that money any more.

We face a lot of consolidation. In the industry where we sit, there are a lot of players where they are not 100% overlapping in what they do. There are concentric circles, but the overlap is not at 100%, meaning that there’s no real true competitor, at least in our case at Redox. Other organizations do some of what we do, but there’s no one that you would say overlap, where someone might say that they could pull Redox and and put in A and it does the exact same thing. What that suggests, if you look across the industry, is that there will be consolidation.

There will be forced consolidation, where companies will go to market because they literally run out of money and they can’t raise any more. Do they close up shop or are they able to merge with other organizations? You are going to see that. It’s a ripe time for companies to get together and start to talk, especially the companies that are in this space, these small fragmented companies, to come together. 

You’re not seeing a lot of these companies being acquired by health plans, payers, and providers like you were several years ago. The way to make yourself more enticing is to come together with somebody else and merge those capabilities that you could have if you think about ecosystem horizontally, where you add pieces to it so you become more desirable and you’re able to do more as an entity.

You will see this year that companies will come together and further their value proposition horizontally. There may be some vertically, but a lot horizontally. You’ll be able to do more across the data ecosystem because you’re bringing together different groups of people. I am 100% confident that you’ll see companies coming together, and a lot of that is a reaction to the VC marketplace, both the funding but also the acquisition, the buying of the assets by those who would behave that way.

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

The company has been in existence for 10 years. The vast majority of that time was establishing itself as the leader connecting digital health vendors to EMRs. In doing so, it created what I would say is a tremendous opportunity to to expand to other types of organizations outside of just EMRs and digital health vendors because of all the connections that the company made during those first, let’s say eight, years. Thousands of connections into healthcare organizations into EMRs, working with over 90 EMRs, for example, in 7,500 healthcare organizations, moving a ton of data. 

The priorities for us are moving agnostically. When a healthcare entity wants to move data from A to B, that could include the cloud, where we have relationships with the cloud aggregators. Those aggregators can then do advanced analytics for their customers. Over the next several years, a couple of years, it’s how we continue to evolve into the payer market, provider market, and life sciences market and complement what we’re doing today. What we do today, but do it for more and more entities and continue to scale. 

Then as we talked about that horizontal view of the ecosystem, how do we continue to build out capabilities, partner, or even acquire? That is the typical thing you think about as a leader, which for me, is build by partner. How do we continue to think about that and do that horizontally, so that when you come to Redox, we can do more and more for you? 

A lot of that will be driven by the ask of our clients. When one of our clients says, “I wish you could do X,”  that’s where I perk up. What would you like us to do? We consider that on our roadmaps about about how we move forward.

Our core DNA is that we enable. A lot of clients say, “You do this stuff that we just don’t want to do.” They want the data so that they can then go do something with it. We enable that. We are an enabler, and a very key enabler. We want to continue with that DNA, but enable more and more people with more and more data at a very secure and fast pace.

HIStalk Interviews Jeff Richards, Co-Founder and COO, SnapCare

Jeff Richards, MS, MBA is co-founder and chief development and operation officer of SnapCare.

Tell me about yourself and the company.

I spent the first 19 years of my career as a clinician and administrator in anesthesia at a large public health teaching hospital here in Atlanta, Georgia. Grady Hospital was connected to Emory University, which where I went to school. I educated clinicians that came in. I eventually moved into a leadership role, where I dealt with the complex balancing act that every administrator does — providing some clinical care, overseeing a staff of almost 100, and doing the schedule, which was the seed for launching this company with my partner in Atlanta.

When I went back and got an MBA in 2016, I wrote a paper about a mobile healthcare staffing app. Out of the blue, a classmate of mine from 19 years before reached out and said, hey, can you help me with my startup? It’s called SnapNnurse. I had not intended to start a company when I went to MBA school, but I teamed up with her and we went out to raise capital. We talked to lots of VCs who said, this is a brilliant idea, healthcare often lags behind, and creating a mobile-friendly platform for clinicians to sign up and for facilities to book staff is right on time, in 2017 anyway. We ended up raising $1 million in seed capital in the summer of 2017, launched the company, had good success here in Atlanta, and created a marketplace with about 60 facilities and 10 ,000 clinicians. 

Two and a half years into our entrepreneurial journey, COVID hit. We couldn’t have known that the platform would scale the way it did or predict the benefit of how we interact with social media to sign up clinicians. We pointed it at that situation, turned into a rapid response company, and essentially grew to a billion-dollar company in 2021 and 2022, deploying thousands of clinicians in all 50 states and scaling into a different entity.

In the last 10 months, we’ve rebranded from SnapNurse to SnapCare because we’ve become a broader workforce solution, not just a contingent staffing mobile application. It’s also well past nurses and goes into the entire healthcare clinician continuum other than physicians, which we don’t staff, but do subcontract.

How has the clinician labor market and the use of contract resources changed in the past year or two as healthcare organizations tried to resolve the pandemic-caused, unsustainable labor cost trajectory?

That unprecedented demand was what was needed at the time. You needed to move clinicians around the country as fast as you could from the different hotspots, sometimes happening simultaneously. As the pandemic waned, that demand went away and went below many of the pre -pandemic levels. 

As that was happening, we had evolved from a technology platform. Our orientation and what we had built changed. We said, why don’t we put the technology that we use to mobilize clinicians, engage them, match them, attract them, onboard them, credential them, and deploy them, in the hands of clients themselves? Why not empower them by plugging them into the software?

As that demand was waning, we were in the midst of rebranding into the company that we are today. Facilities are struggling from contingent staffing. There’s a lot that we can offer them as a company to help them manage their internal staff and attract, credential, and onboard candidates more efficiently than they do today.

The moving around of clinicians was like a shell game, where the supply was limited and the demand for their services was at least temporarily unlimited, which predictably sent pay rates up. Will we ever have enough clinicians to avoid ever-increasing compensation as organizations poach them from each other?

When we started this company, my research in MBA school was in the state of Georgia. In 2007, the Georgia state legislature commissioned a study to better understand and predict the healthcare workforce shortage. What they predicted was that without a massive change in the number of school schools and the number of educators – which is a huge piece of this puzzle – and the investment to support all of that, there would be a healthcare healthcare workforce shortage would begin to peak in 2017, which was when I was writing the paper. The legislature did the right thing and was correct in their assessment, but they did not fund the initiatives that would would have alleviated the problem. 

To your question, the answer is a decade-long investment across the country to enable the number of clinicians who are going into school and the number of educators that are needed. A lot of resources got pulled away as facilities attracted clinicians out of educational roles to work at the bedside. It is a complex problem in the sense that that’s a decade-long fix, with lots of steps in between.

AI will probably play a role in the solution. It’s in telehealth. It’s in the way that you manage the internal staff. We recently did an acquisition, a company called Medecipher, that has a machine learning and AI algorithm for predictive analytics. It helps deploy internal staff across a six- or eight-week schedule to better match the acuity of the clinician, their specific certifications and qualifications, to the census and to the acuity of the patients. They are in different departments throughout a facility. There are absolutely tools and technologies that are on the table to help manage it, but the big picture solution is to increase the supply of clinicians.

I think AI is the future of this industry. It’s often an overused buzzword, but there’s a there’s a fast-paced change going on. Artificial intelligence has changed the speed with which technology keeps doubling the capacity. Moore’s Law, which was established by Gordon Moore in the 1960s, says that the number of transistors in a microchip doubles approximately every two years. Somehow through technology innovations and the number of chips and the way we make those chips internationally, we’ve maintained that.

Everyone thinks that AI has only come along in the last couple of years, but it has been decades in the making. But in the last 12 years, the speed with which the capacity for AI — which is software, it’s not hardware — has been doubling at a rate of every 3.4 months. It gets a little geeky to get that specific, but the highlight is that at the end of the year, it’s 400% more capable. Every quarter, things are getting faster and faster and faster. 

I think we are in the beginning of a two-ish year run where the way facilities and clinicians engage will be heavily driven by AI. The companies that figure that out and leverage it will be the leaders ,and clinicians will be attracted to them because of how they can interact, get access to jobs and onboard, and maintain their credentials. All of it will be significantly easier than it is today.

How are organizations using an internal resource pool and related technologies to reduce their reliance on higher-cost outside resources?

The internal resource pool for us is a natural, the other side of the coin of the Medecipher acquisition. Number one would be to deploy Medecipher and use no contingent staff whatsoever, just better utilizing the staff that you have. Then combining it with our platform, which has a shift booking engine and matching algorithm to ensure that every facility has a pool of PRN type candidates, often without benefits at a slightly higher rate, who do that for flexibility. Maybe they work at two or three locations around town.

Most organizations don’t have the technology to send out the shift requests, send reminders, and ensure that once they do work, they get notifications to submit time cards and things like that. This is basic technology that we have used for years, and that is the offering to take that and use it to develop internal resource pool. We think that the smartest combination is to combine that with a predictive analytics scheduling solution.

Moving people around to unfamiliar facilities with different practices must create some degree of patient safety risk, plus it seems logical that a clinician would prefer to pick up extra shifts at their home organization rather than moving around. Are employers trying to create an environment to support that?

Absolutely. The facilities as employers want to ensure that. The larger part of their workforce is made up of full -time employees with full-time benefits and the facility is working well for them. But there is always a sizeable percentage, five to 10% – which is hundreds of people when you’re talking about 4,000 or 5,000 clinicians — who want  to work in a more flexible way and may opt out of benefits. It may not be that they’re moving to different facilities across town. It could be that it’s a system that has two or three hospitals that are in relatively close proximity. For the option of the flexibility, to have a little more control over their schedule, they are willing to opt out of benefits.

To move them around and to mobilize them in the smartest way, you need a technology platform that can help distribute the shift requests, send reminders, and support an on-call backup auto notification that can go two or three levels deep into those who didn’t get the shift but have opted in to be in an on-call capacity.  Those are basic bread and butter techniques to ensure that you have the staff when you need them and where you need them. That technology, whether its sounds staggeringly innovative or not, is missing in most facilities. We offer it as a platform.

What are the benefits of your transparent pricing promise?

We hear from facilities the same thing that I felt myself as an administrator at Grady. I’m paying this high bill rate, but what are you paying the clinician? Inevitably, somebody will get it out of the clinician. Administrators are already frustrated because they don’t want to be using contingent staffing, so they do it in a somewhat begrudging way. But it should be transparent. You should know where the dollars are going. When you’re hiring someone at a premium, dollars also go to the stipend, because you’ve relocated them. If it’s a local contractor, then you’re going to see what that margin is. 

It’s a promise of trust to our clients that when when they use contingent staff, they know what it costs. We have such trust and confidence in our technology that we have driven the cost down. Those margins are much lower than a traditional legacy staffing agency, which often has brick and mortar buildings, a larger group of staff, and lower utilization of technology that require it to maintain a higher margin to pay for all of that.

Why do health systems use your services to recruit for making direct hires?

Some facilities need to make 300 hires and their HR department is not up to do that, so they seek us out. The way we differentiate ourselves is twofold. Because of our cost structure as a technology company, we can do it for less and have some of the lowest one-time costs for permanent placement when you’re doing direct hire. Then, the way we combine the our platform with social media to reach out to candidates is a broader way to access them and whatever pools they are in. The message leverages what the facility wants to do, whether they want to have an incentive like a sign-on bonus or speak to the benefits that they offer at their facility. Our reach and the interactivity of the platform with social media is another differentiator. Overall, it’s cost and the technology platform itself.

Where does the company go from here?

It’s really the shift from external contingent human capital management — the contingent staffing world whether technology enabled or not — into an increasingly pure SaaS product, where significant elements of the business are dedicated to predictive analytics. That’s the reason for the acquisition that’s only two months old. Leveraging the internal resource pool, and only when they have exhausted those techniques as well as permanent placement and have decided to use contingent staffing, to use a best in class marketplace that can aggregate PRN contract staffing, leveraging the technology across multiple different agencies to leverage the cost, get it down. We differentiate ourselves from contingent staffing competitors by seeing ourselves as constantly transforming further down the pathway towards a technology-only company.

HIStalk Interviews Russ Thomas, CEO, Availity

Russ Thomas, JD is CEO of Availity of Jacksonville, FL.

Tell me about yourself and the company.

Availity connects health plans and providers for their critical business workflows. Most people would call that a clearinghouse, but we think of it as a 21st century clearinghouse because we add a lot of intelligence around the workflows that we facilitate between providers and payers.

We’ve been doing that for almost 25 years. The company started in 2001. Today, we serve well over 3 million providers around the country. We will process $3.5 trillion of claims through our network this year.

We are big believers in what we call multi-modality. We take providers however we find them. If they are sophisticated providers working in their Epic environment, we love that. We are deeply integrated with Epic with our revenue cycle product. At the same time, we have literally millions of providers who access their payer information through Essentials, our real-time, multi-payer portal. That gives them the vast majority of the information that they need, day in day out, to run their business. It serves all types of providers, not just physicians, but anyone who’s providing healthcare to a patient and getting reimbursed by health plan. Think about Medicaid, which includes atypical providers — ramp builders, transportation companies, or somebody’s aunt or uncle or mom or dad who is getting reimbursed for providing care to them.

What are the most urgent opportunities in improving communication between providers and payers?

The most urgent opportunity is quality of information. We are very good at building and deploying technology to facilitate the exchange of information in a timely way to the right person with the right information that they need. The underlying quality of the content has to continue to improve. Authorization workflow is facilitated today between most health plans and providers. Trying to figure out that translation of provider-speak to payer-speak often involves phone calls and faxes, and wait times for authorization are still long.

In that example, we have found a way to automate that workflow. We acquired a company about a year ago called AuthAI and have implemented that with one payer, with others in process. We are literally creating a real-time exchange of authorization information, facilitating that authorization workflow in under 90 seconds, all the way through a medical necessity determination. It’s a huge provider satisfier and works great for the payers as well, bringing value to both sides of the equation.

Right or wrong, I assume good intent. I assume that providers only want to perform procedures that are appropriate, medically necessary, and good for patient care. I assume that payers want to pay the fair contracted rate for that care. If the administrative workflow is slowing that down, creating obstacles, or getting in the way of good medical practice and good reimbursement practice, it can be more trouble than it’s worth.

We focus on eliminating those administrative workflows that just get in the way and aren’t providing any value. They were put in place with good intentions at some point in the past, but now they are not helping to improve either patient quality or the relationship between providers and payers.

What impact will patients see from federally mandated payer-to-payer APIs?

We have launched that. We have our first cohort of payers implementing now. I think it’s three or four that we’re starting with and our second cohort is right behind it. Transparency, right? Interoperability.

Availity is in Jacksonville, FL. We have been a Florida Blue company for a long time for our health coverage. If we decide to move to somebody else, my data shouldn’t be siloed in the Florida Blue environment. There’s tons of opportunity to improve patient care, to improve transparency, and to make the provider’s job easier by mandating the exchange of that information between payers when either I individually or my company makes a decision to make a switch. It’s freeing up data, which is what I love about it.

What are your biggest takeaways from the Change Healthcare cyberattack?

I anticipated that question, but I still don’t know that I have the best answer to but a couple of things.

Security is paramount. We talk about it in terms of resiliency. Resiliency means that you have a you have a really good Plan A, which is to maintain the highest possible level of information security to protect your network. You’re going to see us advocating for this as a company.

The bar is higher for firms who do what we do. The bar for clearinghouses needs to be higher, for both the level of information security that we maintain and for the resiliency or redundancy of our networks, because the alternative to that is to try to figure out how to protect millions of endpoints. I don’t think that’s a fair burden to put on providers in particular, who are already stressed and trying to run businesses that are financially struggling in some cases.

We have been advocating aggressively in the last couple of months with CMS. Congress has gotten involved and should be focused on hardening the network itself, so that physicians and payers can continue to collaborate effectively.

Information security has to be your Plan A. You have to be world class at it, and it needs to be a culture within your organization. It certainly is for us.

Then, candidly, you need a redundancy plan. Your Plan B that assumes plan A fails at some point. When there is an attack, and when there is an impact from attack, you have to be able to bring the network back to full strength in time periods that are measured in days, if not hours, not in months or quarters.

The takeaway for us is that as good as we think we are from an information security perspective, we have to continue to get better, better, and better. Invest more and bring more resources to bear. Challenge ourselves to think differently about how to protect our network. We have to make sure that our redundancy plan remains strong. We’re doing things today to make sure that we are fully cloud migrated, so that when or if something happens, we are able to move environments really, really quickly and have as little impact on our clients as possible. Those are the key takeaways.

I’m at a large health system today where we extended the Availity Lifeline. Not to brag, but I think we’ve done a really nice job of helping providers get back in business. We’ve stood up 300,000 providers in the last 65 days and moved over $160 billion of claims that would have otherwise been stuck. As you can imagine, that has allowed us to make some really good relationships. One of the things that we are hearing from these providers is that we have to have a backup plan. Being on our own and having one system has worked for a long time, but we really need to think about how to create redundancy in our own network with a solid backup plan. That’s a takeaway not just for Availity, but for a lot of providers.

We were at our annual client conference in Arizona when the cyberattack started on February 21. We took the correct immediate step to disconnect from anything with a “U” in front of it, not just Change, but all of the Optum environments and all the UnitedHealth Group environments that we were connected to. We then said to ourselves, we don’t know how long this is going to last, but there will be providers and payers who need some help. We created this program called Availity Lifeline to bring claims and remits back up. We stripped down our revenue cycle product into a really simple, fundamental version of it that was just claims and remits, which are the lifeblood of the business relationship between a health plan and the provider.

We went out to the market and said, we’ll make this available to anyone who needs it, free and with no strings attached. You can terminate it with five days notice. You never pay us a nickel, but in the short term, this at least will help you as a health system to get claims and remittance flowing again so that you can continue to run your business while you figure out what you want to do. It’s been very successful, with 300,000 providers and 150 or 160 actual systems that have implemented Lifeline. As I mentioned, we have moved $160 billion of otherwise stuck claims between payers and providers.

UnitedHealth Group paid the hacker’s demanded ransom, but was still down for many weeks. Oracle’s Larry Ellison said that they could have come up quickly if they were running Oracle Cloud. Is it harder to recover a complex network than to restore a health system, and does cloud provide a lot of extra recovery benefit or just a head start?

Cloud gives you a ton of extra benefit. If you listen to UHG CEO Andrew Witty’s testimony to Congress, there was a lot of older technology behind the scenes of Change. That created some real challenges, based on what they have said, in terms how the bad guys got into the network and had the ability to root around for a week and half before they actually pulled the lever on the actual ransomware attack.

Being cloud-enabled absolutely is advantageous in getting networks back up faster when there’s an event. I don’t know whether Larry’s right that it would happen in minutes. From the Availity perspective, we are completing our cloud migration. We run two data centers, but we never have them both processing transactions at the same time for that very reason. One is primary and one is redundant.  If we had to move from A to B, we can do that in three to six hours. We also do some other things to protect our core data with things like immutable backups that nobody can touch. It’s a journey, but we are absolutely counting on our cloud migration to give us even further redundancy and resiliency against a cyberattack.

You’ve acquired Diameter Health and the Olive’s utilization management business since we last spoke. How did those acquisition round out your portfolio?

The first thing that we do, even in due diligence, is cyber audits and cyber reviews. Before we close, what do we need to do to bring an acquisition up to our standards for information security? We don’t do anything to combine, from a technical perspective, those kinds of capabilities until we have brought them up to standard if needed.

Diameter was a great acquisition. The best analogy that I can give is that it’s a refinery for clinical data. Unlike administrative data, a lot of clinical data has no structure. There are no standard terminologies that everyone uses. You get a lot of data in, but aren’t able to use it and apply it to business workflows in an automated fashion. Diameter upcycles – we use that term – and refines clinical data from a lot of different sources into consumable data elements that can then be implemented in an automated workflow. We are very happy with that acquisition. It is really core to our broader clinical data, clinical interoperability standard today.

AuthAI, likewise, has been great. We bought it with one client. We’ve now sold it to multiple clients. It is a true delighter. The difference between AuthAI and Diameter is that Diameter is more of an internal technology, while AuthAI has a user experience. We can walk into provider’s office and say, “We we have automated your auth workflows for the vast majority of the ‘ologies’ that you work with. Now you can get a response in 90 seconds, all the way through medical necessity determination.” That’s a difference-maker to a provider.

How will AI affect your business?

AI is going to give us new capability. We are pretty committed to it at this point. AuthAI is built on the premise that analytic AI is a great tool to apply in complex healthcare workflows. We’ve certainly seen that with our AuthAI solution. Internally, we are leveraging AI to simplify both our own workflows and our relationship with our providers and health plans and other customers.

I’ll say one thing as an example. I got demos yesterday from two really cool companies, not startups, but sort of earlier stage. One that is on the provider side is leveraging AI in clinical documentation to help providers by essentially transcribing their clinical conversation into an application, then leveraging AI to create a true clinical note and applying what the AI believes are the proper billing codes, ICD codes, to that note.  Great. That could be a real time saver for providers.

The other demo later in the day was an early-stage AI company that was building what you and I would call, from our experience, fraud, waste, and abuse capabilities for payers. They use AI to look at the pattern of how claims come in and the documentation behind a claim to make sure that the claims are appropriate and medically necessary and therefore should be paid.

If you think about those two conversations individually, on both sides, they are cool, save time, save energy, and drive efficiency. However, you have to make sure that you achieve true transparency and enhanced decision-making to get to the right result. I don’t want to arrive in a year or two at a scenario where payer AI and provider AI are arguing with each other over whether a claim should have been a denied or whether a code should have been paid.

To the extent that AI can be applied like we’ve applied it with AuthAI to automate a workflow, in the end, between a payer and provider, where everybody’s agreeing to the rules of the road and you are leveraging the AI to drive a more efficient, effective process, the promise of that is just spectacular. That gets me really excited.

CMS’s pay-and-chase policies and perhaps its lack of sophisticated technology allow seemingly obvious fraud to take place over years before someone might be brought to justice. Couldn’t technology detect outliers more quickly?

I think there’s a great opportunity there, 100%. We sell our Advanced Editing Services product into Medicare through the MACS. It is built in with as a real-time editing capability so that you can continue to learn where games are being played or where there’s potential for fraud, waste, or abuse. You can build new edits in real time and deploy those prospectively. Why are you paying this and going after it? What you should be doing is applying the rules prospectively to deny the activity or to prevent the activity in the first place. That is 100% where we are focused as a company.

I don’t think that’s just to protect from bad activity. We are focused on it in terms of shifting left. Availity serves as the gateway for payers that are representing well over 100 million covered lives in the US. Generally, all claims and all activity flow through Availity. We believe that through the application of technology, including AI, we can make our gateway smarter, so that by the time we pass a claim onto the payer, It can be screened for nefarious activity, but it can also be screened for clinical appropriateness, proper documentation, and all the things that are required to pay a claim accurately and in a timely fashion.

What are the key points of the company’s strategy over the next five years?

We have a good thing going at Availity. We have a pretty unusual capital structure in that some of my largest customers in our health plans are investors in the company. We have a really good culture at the organization, with people who really believe in our mission. In the next five years, we will continue to do what we’re doing today to drive better collaboration, better partnership, and more transparency of information between payers and providers.

Then, to eliminate some of these lagging, complex, administrative problems that drive hundreds of billions of dollars of inefficiency in healthcare and just piss everybody off. No patient wants to stand at the MRI counter waiting an hour for their auth to be approved or to be told that even though you have a scheduled appointment, you have to come back tomorrow because I can’t get your auth approved.

Good, bad, or otherwise, we have just scratched the surface on some of these super complex challenges in healthcare. Availity has in important role to play over the next five or 10 years in simplifying the process of healthcare.

HIStalk Interviews Paula Scariati, DO, Physician Informaticist and Author

Paula Scariati, DO, MPH, MS is a physician informaticist, EHR governance consultant, and author of the book “EHR Governance: A Practical Guide to User Centric, Consensus Driven Optimization.”

Tell me about yourself and what you do.

I’m an preventive medicine and public health doctor. I fell in love with the promise of what technology could do to make patient care and access better, so much so that I left the private practice that I had in San Diego 15 years ago to formally retrain in informatics.

But nothing that I learned in my academic studies really prepared me for my first job as a physician informaticist in a large, enterprise healthcare system. Providers were frustrated by poorly designed software, inefficient workflows, and low-value tasks. EHR governance was immature, and was often driven by well-meaning executives who didn’t really use the EHR. End-user requests were low priority and frequently lost to follow up.

In short, the processes were slow, poorly coordinated, and had lots of bumps, detours, and do-overs. It was intense. The tipping point came when a large region that was part of the enterprise threatened to return to paper, and there was a crisis. Out of that crisis, a methodical, user-centric, Agile approach to EHR governance was born.

How has EHR governance changed now that most health systems have chosen and implemented an EHR?

Governance has matured organically over time. In the beginning, back when most organizations went live, it usually meant that a process was stood up at the end of go-live, where that critical mass of requests that were made during go-live, but not necessarily addressed during go-live, were handed over into a queue.  That was the focus of early governance work, the robust adoption of a new system with well -integrated workflows.

But once those I’s were dotted and T’s were crossed, the focus of governance then shifted to optimization. That work included end users adopting new tools and refining interfaces. This organization was looking for more effective, efficient care. It took probably several years for that to unfold. 

Then the organization moved on to the next phase of EHR governance, which I call transformation. It’s at that point where the organization’s governance framework would be well established and trusted. It has become part of the cultural norm of organization. There’s now a pathway, hopefully an Agile pathway, for conducting pilots or proof of concepts, which allows the organizations to quickly vet new technologies, modules, and features. There’s also an established system for communicating and socializing change.

I’d like to believe that over these last 15 years, many organizations have found a level of transformational maturity in their EHR governance processes that works well for their healthcare system and their culture. However, I’ve also spoken with so many leaders and organizations where EHR governance never got a strong footing, or where well-designed governance processes were fouled by mergers and acquisitions or major leadership changes.

Do health systems incorporate the participation of medical staff technology naysayers in addition to the “friendlies” who will reliably support most executive decisions?

EHR governance needs to be led, and it needs to be led by somebody who is well respected and has the power to make changes when they need to. That right person needs to be embedded in a consensus-driven governance process. That process needs to listen closely to everybody. People who say they’re doing a good job, but especially the people who tell them that they are not.

Sometimes that negative feedback is more representative of the truth. Sometimes it isn’t representative at all, but it’s the canary in the coal mine, meaning that that person has the unique ability to see a real problem before others do. Occasionally, it might be a disruptor who has a less-than-kind intention, who can in good faith be ignored. 

But it is important to remember that a solid EHR governance structure is a two-way street. Communication goes out, but communication also comes back in. You need to be listening to the voice of the end user. Because when that is done well, a responsive governance process can throttle and balance an organization between that need for change and that problem with inertia or the status quo. Every organization has a different level of tolerance. A good system will recognize that and reduce the amount of fatigue and burnout that an organization will have because it is keeping to close on what’s going on.

Early EHR decisions were often made without thorough physician involvement, or by departments that wanted to make their own jobs easier by using the EHR to push more work onto physicians. Are some of those decisions being revisited or are physicians being asked directly how the EHR hurts or could help their work?

I think it’s safe to say that every organization that adopted an EHR back in 2009, which is when HITECH was enacted ,would have been thrilled if the software was mature and user friendly. But we have to remember that every vendor’s core EHR product was initially designed to meet Meaningful Use metrics, and that went on for seven years. Nowhere in there was a mandate for the user interface to be friendly or for the user experience to good. 

That exists even today. Our former Meaningful Use metrics have now morphed into the Promoting Interoperability Programs and eCQMs. This is all the basis for driving value-based care, but it took a number of years for that emerging body of literature on the unintended consequences of EHRs, note bloat, provider fatigue, and burnout to elevate the importance of the end-user experience and push it to the forefront. Physicians were rightfully frustrated and local decisions were made, decisions were made by the vendors, but they weren’t made with the idea of how to improve the user experience. They were made, how do we meet this metric? How do make this quality metric or safety metric get reported so that we can obtain Meaningful Use dollars? 

There was also a lot of frustration on the part of physicians because they were now being asked to play well with others in the sandbox. They were asked work with their colleagues and other teams to come to a consensus on how to design their user interfaces and workflows. This was a difficult task for some specialties, such as cardiothoracic surgeons who might be used to having their own unique way of doing things. This is where having fair, transparent, equitable governance processes is incredibly helpful. It levels the playing field and it sets consistent expectations.

Physicians are just about the only professionals who are expected to enter data into a computer system while doing their jobs, and often the data that they are recording doesn’t benefit them or their patient directly. Is AI or the use of scribes likely to change that?

Forcing physicians to become data entry clerks has been one of the greatest failings of EHR adoption process being driven by Meaningful Use. AI will get the keyboard off the physician’s lap, which will go a long way toward restoring the doctor-patient relationship. In fact, the highlight of HIMSS24 was the latest iteration of ambient voice technology married to artificial intelligence. These types of software capture the doctor-patient encounter verbatim and then use AI -driven logic to digest that information into a succinct, readable node. It’s amazing, and I think it’s just the beginning of what AI that is thoughtfully utilized in healthcare can do. 

However, there’s a lot of pressure on AI to solve all the problems that we have. It would be very nice if it can do that. I’m waiting and hoping that that will be the case. Some people say five years. I am a big fan of following Eric Topol’s voice in the matter, and I think he’s more optimistic than most in terms of how quickly this will unfold. But either way, I think it’s going to go a long way to help correct a lot of the problems that we’ve encountered as a result of how our initial work with EHRs has happened over the last 15 years.

How does the art of medicine coexist with the use of technology to standardize processes and guide medical decision-making?

When we first started digitizing medical records, a good deal of folly took what was on paper and just made it digital. We didn’t really use the knowledge that we had of how to make the EHR better, stronger, and faster than paper ever could be. But now, we see that the science underlying medicine grows exponentially every day. Just look how much medical literature is published each day. Then there’s the patient’s genomic data and now their phenomic data and so much more. It is absolutely impossible for any one provider or provider team to keep pace without using electronic tools that can securely capture, store, and make some good sense of it all.

What I see on the horizon is that good clinical decision support tools and analytics are going to expand the horizon of the physician. But the road to getting there is going be bumpy. We haven’t really taught our physicians or given them tools in a way that are user friendly. That’s where governance comes in, helping us to figure out how much we can change, how quickly we change, and vetting stuff ahead of time so that we determine what kinds of problems it may have and then deploy it using that group of early adopters who likes to do that type of initial pilot or proof of concept work, and help them to become the agents of change within our organizations.

Epic’s implementation model involves a rigid methodology and the assumption that C-level hospital executives will follow the recommendations of vendor employees who might have been sitting in a college classroom a year or two before. Did that level of prescriptive vendor involvement change the way that hospitals implement technology?

I gave a talk yesterday and user experience with Epic.The takeaway is simple — incentivized behavior change is more effective, and Epic was very smart. Early on, they recognized that organizations didn’t know what they didn’t know, and so they led. They were prescriptive. They trained and deployed resources. They didn’t nickel and dime their customers, but the level of support that came with them had a larger price tag and, in the end, better customer satisfaction. I’ve spoken with a number of organizational leaders that have used Epic and other EHRs, and they consistently they tell me that they find the Epic model to offer added value.

The takeaway is that incentivizing behavior change, being prescriptive — especially in an environment where people are learning something new, where they don’t know what they don t know — is a valuable way to deploy something. 

Is governance different in Epic-using health systems, either because they are self-selected as large, academic medical centers or because they are influenced by Epic or its other customers?

Epic had its origins in the ambulatory world. A number of Epic installations are organizations that have brought together large groups of ambulatory providers. We used to call the ambulatory world the wild, wild West, because in the inpatient world, a large, complex go-live has a lot of moving parts, while the ambulatory world, each individual practice has its own way of doing things. When you try to bring that together under a governance structure, it’s a little bit more challenging to get people to talk to each other or get them to agree on a certain interface or workflow.

In my experience, maybe not in everybody’s experience, taking the time to draw on a group of leaders to represent a specific region or practice and bringing them together to drive the change that you call governance is critical. 

Another good example of that is watching what is happening now with the go-live for the VA. Very, very bold. They are trying to have the whole VA system and the Department of Defense be on a single instance of Oracle. That’s a bold undertaking from a governance perspective, in terms of having everybody work together and use that same platform in a similar fashion.

Implementation of AI is more of a blank slate than bringing up an EHR since health systems can set up just about any logic and workflow they want, good or bad. How will AI governance work?

I wouldn’t necessarily say that we have a blank slate today. We’ve now been through over a decade, almost 15 years following HITECH, of doing EHRs. Some organizations have been on that same EHR, while others have gone through a second go-live with another EHR. Some have gone through mergers and acquisitions.  

What I see, and what I keep hearing from the different organizations that I speak with, is that physicians and other healthcare providers and users are tired of that “unlearn something old, learn something new” unlearn-relearn technology cycle that we’ve entangled our healthcare providers in. Our human nature is more inclined towards inertia and the status quo than it is to these iterative cycles of rapid change. For example, I may offer a physician a better, more efficient way to do something, but it’s not that unusual for them to decline, saying they would rather keep their current process and workflow even if it is broken. 

I see what’s coming forward with AI as incredible. It’s going to be another technical revolution. But I’m concerned that we now have a large amount of change fatigue, and in some cases burnout, from all of the change that we have been throwing at providers for the last decade and a half. They predict that the way we practice medicine will completely change in the next five years, and that is both exciting and frightening. But solid AI governance processes are the key to helping organizations throttle how they unfold that technology so that we have a legacy of innovation and equity, not burnout and the dissolution of the doctor-patient relationship.

More physicians on the medical staff are employed directly by health systems now instead of being based in the community or contracted through an external company. How has that affected the integration of physicians into technology decisions or their ongoing technology training?

I always found that group of community-based doctors to be an outlier in how we handled them during our lives. Their office often used a different EHR than the one in the hospital where they worked. It wasn’t a given that you would automatically just bring them up in their practice on the same EHR. They would use some sort of interface in their office to be able to use their office-based EHR that was interfaced to the hospital EHR. That was a clunky way of thinking about things, and something that I really had wish we had been more forward thinking about in terms of continuity of care across the continuum of care in medicine.

I would not say that it’s a big difference in terms of how we engage with them. Often they were powerful because they brought  lot of money into the organization, so there was a high level of sensitivity to making sure that their EHR worked well for them. But engaging them in governance and in consensus was the same as it was for any other group.  Again, with that added caveat that when we were looking at workflows, it was the hospital-based workflows and not necessarily how it would always work for their EHRs within their office.  But we often would go out and do a visit into their offices just to make sure that there was something that was working well and that it wasn’t double entry, or that something was inclined to making more errors than not.

How do you see the role of the CMIO changing?

I am hopeful that CMIOs over the last decade and a half have shown that they are strong leaders. I would love to see them elevated from what is oftentimes a “small C” in the organization to a “large C,” where they have a seat at the table with the CEO, CMO, and CIO. They do in some organizations, and some they don’t. But there has been recognition of the expertise that they bring to the table, as well as an evolution in what the CMIO is expected to be able to do, that has caused that role to be elevated to a higher level. 

As we move towards more AI -driven technological revolution in healthcare, that voice, that person, and that expertise is going to be critical. Over time, roles have been renamed. They have become the chief digital officer or chief AI officer. It may go that way instead of just changing the world of the CMIO to embrace a broader swath of what is technology. They may create these other roles that are more specialized. Either way, the CMIO has been elevated in stature and importance within every organization that is seeing just how much technology touches every aspect of healthcare.

HIStalk Interviews Kelly Boyd, SVP/GM, Sonifi Health

Kelly Boyd, MBA is SVP and general manager of Sonifi Health, the healthcare division of Sonifi Solutions of Sioux Falls, SD.

Tell me about yourself and the company.

I’ve been working in healthcare technology for about 20 years. The bulk of that time has been in product development and operations. I have spent time with the customer success and sales aspects.

Sonifi Health is a wholly owned subsidiary of Sonifi Solutions. Our parent company serves hospitality and other commercial markets. Sonifi Health focuses exclusively on the healthcare market. Within Sonifi, both the parent company and our subsidiaries, we have an underlying theme that our goal is to simplify the delivery and operation of technology so that our customers can accomplish all that’s possible when technology works. Technology is great, but it needs to complement the organization where it’s being deployed. Our role and our goal is to simplify that process, make it seamless, and make it valuable to the organizations that deploy it.

We still fundamentally align ourselves with the Triple Aim initiative that was launched by IHI back maybe 2007 and later modified to the Quadruple Aim. We want to enhance the patient experience, improve health outcomes, and drive operational efficiencies. That translates to both cost reductions and staff satisfaction. That is where we live. All of our technologies — smart room technology, staff technologies — are built fundamentally to go after those initiatives. 

You emphasize that healthcare is hospitality. Do you think that most hospitals see it that way and invest accordingly?

I do. We’ve doubled down on this, because in technology and healthcare tech, we can get so caught up in technology itself. The hospital’s mission is patient care, and at the root of that is compassion, comfort, and health outcomes. That essentially is the real meaning of hospitality.

We have launched with that messaging, both to remind ourselves internally and also message to our clients that we get that technology doesn’t exist for technology’s sake. At the end of the day, everything that we are doing is about the human experience. Creating an environment that is comfortable to the patient and that reduces anxiety has a direct impact on outcomes.

Patients aren’t necessarily capable of judging the clinical aspects of the care that they receive. Does the hospitality aspect of their stay carry an outsized importance in their perceived satisfaction?

It’s interesting, because patients aren’t able to perceive different levels of true clinical care. They can attribute that “I survived that surgery, therefore it was good,” but they can’t really assess where that surgery ranked on the spectrum. What they can definitively create is the perception about how they felt were treated and the hospitality side of the care that they received. People can articulate those things more than they can the true clinical aspects of healthcare.

Patients sometimes complain that technology, such as a physician charting in the EHR, is distracting. How do they see in-room technology and smart rooms?

There is no downside to the technology from the patient perception side. We have seen bumps in hospital patient experience scores simply from bringing in smart room technology. Patients translate high tech, cutting edge, state-of-the-art automation technology to better care. Whether that is a fair translation or not, it happens.

People are human, and investments on the hospitality side impact our perception of the quality of care that we are going to receive. Is my room nice? Is the furniture nice? Is the TV nice? Anything that a hospital does to to move to a smart room to enhance the environment impacts the patient’s perception of their quality of care, and to some extent, how they will perceive their outcomes.

Your website cites a study that found that patients who use an interactive, in-room system are more likely to also use it to follow education recommendations. How can hospitals use that finding?

We found that the entertainment side of it draws people into the system. You want to watch that movie, listen to the music, engage with spiritual content, or whatever those entertainment pieces are that bring the patient into the system. The system is then designed to capitalize on the fact that the patient is engaged with the system.

We will strategically prompt the patient to engage in their care as well. That can be learning about their condition, how the recovery will go once they go home, things that they should watch for once they leave the hospital, and what they need to do to plan and prepare for their discharge. We leverage the entertainment side as a way to pull the patient in, but once they’re in the system, you have all kinds of opportunities to put the important information in front of them.

Do you engage family members in that process?

We love involving family members. When you’re a patient, there is a little bit of anxiety. You’re unsettled. Your ability to grasp the information is much different than a family member. We encourage the family members. We know that the the information lands and and sticks a little bit better when the family members are the ones participating, especially when you’re talking about young children or the adult caregivers of their elderly parents. The family members play a big part of it.

As a parent, I’ve been in the hospital with my kids and I was starved for information. What’s next? What should I expect when I take my son or daughter home? We see a lot of engagement with family members with the system.

How will patient engagement technologies be used outside the four walls of hospitals, such as with hospital at home or virtual hospitals?

This is a trend based on initiatives to reduce costs. It’s clear that the more comfortable the patient is, the better healing, recovery, and outcomes that you’re going to see. The challenge for everybody in healthcare — healthcare tech providers, payers, all of that — is educating patients across the board on health literacy, recovery, lifestyle changes, behavior, and all those things. Companies like Sonifi are trying to increase the engagement and activation of patients so that they can be successful in a home care or hospital at home environment.

How widely are hospitals using digital signage and way-finding?

Most hospitals have some type of digital signage in play. There is a need to continue to get information into the hands of patients and visitors. This could be population health content, where you have people sitting in waiting rooms and have an opportunity to get the right controlled messaging content in front of patients and family members. Signage is everywhere. There’s a lot with branding and marketing of the health system’s mission and vision.

With way-finding, you’re talking substantial institutions that exist on campuses and multi-building setups, where they are trying to make it easier for patients to navigate the campus and get where they need to go.

For Sonifi, we have the nationwide field service organization. We are already providing technology, the breadth and depth of our knowledge of infrastructure, and these type of messaging tools. This becomes a complementary solution for us that we can deliver alongside our more clinical applications.

What are your thoughts about having worked for the same company for nearly 30 years?

When it comes to Sonifi and Sonifi Health, I really love the people that I work for. We’re based in the Midwest, so we have an organization of people who are really committed and care. That “Midwest nice” thing really comes through with the group. I have people in my team who have been here 30 years as well. I have people who have been here 15 years and they joke that they’re the newbies. 

The group believes in what we do. They care about the patient. They care about the the nurse and the clinician. They care deeply about the operations person who is trying to run and manage the distribution system. Everybody is behind what we’re doing, which makes it easy to come to work every day and makes it easy to stay and commit with the organization.

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

We are tracking the movement away from inpatient new construction dollars to the outpatient side, with more short stay-focused, hospital-led home initiatives. Interoperability, security, data exchange, and seamless experiences across multiple facilities are big on our radar as well.

HIStalk Interviews Gene Scheurer, CEO, Optimum Healthcare IT

Gene Scheurer is co-founder and CEO of Optimum Healthcare IT of Jacksonville, FL.

Tell me about yourself and the company.

Jason Mabry and I started Optimum Healthcare IT in 2012. I had started CSI Tech, which we sold to Recruit in 2010, so we put the band back together in 2012. We were primarily focused on EHR implementations and rode that wave. We were #1 in KLAS in multiple overall services for a couple of years. We grew the business exponentially during that time.

We spun off Clearsense in 2016. That’s a data aggregation, data platform play. I went over to Clearsense in 2018 on a full-time basis to be the CEO. I promoted Jason Mabry and then Jason Jarrett into the CEO role at Optimum. I’ve been at Clearsense since. We signed some of the largest healthcare systems in the country as a data platform company. UPMC is a client and investor, Cleveland Clinic, Trinity, CommonSpirit, et cetera. We grew that business and started getting into the payer market as well.

As we made the transition to more of a product company and going into the payer market, I came to the realization that that isn’t really my strength. I went to the board nine months ago and told them that it was time for me to pass the baton and for them to find a CEO who has a product and technical background and payer experience.  We did that in January of this year and now I’m back at Optimum as CEO on a full -time basis. I was always executive chairman at Optimum, so I had kept close to the business.

In 2020, we sold a majority interest to Achieve, which is an educational fund out of New York. We weren’t necessarily looking to sell, but their business model is to tap into their network of university partners. We created CareerPath, where we take kids out of college or with one or two years of operational experience and put them through a six-week healthcare IT curriculum and certification that is operated by CHIME and is exclusive to Optimum. They get a healthcare IT certificate through CHIME and then we put them on a track to get certified in Epic, ServiceNow, or Workday. We also do project management and BI.

It was a good opportunity to add talent into the marketplace from a supply and demand perspective and to lower costs to our customers by offering up-and-coming resources. We can reduce those pay rates to those individuals and ultimately pass that along to our customers.

After we did that transaction in 2020, we did an acquisition of Trustpoint Solutions, which focused on cybersecurity advisory. Then we added ServiceNow and cloud migration services and earned Workday certification.

How do you deploy both experienced resources as well as those you have developed through CareerPath?

We still do Epic implementations and we have 600 employees, so we still are providing opportunities to those consultants who have been in the ecosystem and have experience for 10-plus years. The CareerPath model, with more junior resources, was an option to offer a hybrid. We can marry highly experienced team leads with junior-level resources from an analyst perspective, and they can do some mentorship. It’s a way to drive down implementation or optimization costs for our customers while creating a new talent pool for ServiceNow and Workday.

What areas do health systems need help with?

We have new clients that are doing new Epic installs and there’s a lot of Cerner to Epic migrations happening. We also have some Meditech to Cerner customers that are doing new implementations. We have opportunities for new installs, training, go-lives on new-new implementations, and optimization.

A lot of healthcare systems have financial headwinds. They have made a large investment in the EHRs of their choice. They are optimizing those to make them as efficient as possible. We are asked to do a lot of workflow redesign and revenue cycle projects.

On the ServiceNow side, we have become the only Elite partner in healthcare. They are looking more from a vertical perspective right now. Healthcare is so nuanced in terms of understanding the landscape and workflows and everything that goes into healthcare. It’s probably one of the most dynamic and involved of all the verticals that they have, so they love the fact that we are healthcare focused. We bring to bear a lot of advisory around the healthcare landscape in conjunction with the ServiceNow and Workday implementation.

Where are we in the always-swinging pendulum between healthcare outsourcing and insourcing of IT and revenue cycle?

We are seeing a lot more insourcing, as opposed to outsourcing. Those cycles always change, but within our customer base, we are seeing a lot of insourcing, coming back into the revenue cycle space. That is good for us because we can partner with our customers to help them bring in consultants to stand up those revenue cycle initiatives as they get operationalized and then get to a steady state.

Are you seeing any impact from AI?

The software partners that we’re working with – Epic, Workday, and ServiceNow – have incorporated AI into their software and technologies. Everybody is using AI to some degree, and it’s typically use case specific. It’s a lot of buzz, but as it matures, you’ll start seeing AI’s true ability to demonstrate real results. A lot of it is embedded into the software, behind the curtain in a lot of ways, and people are using it one way or another even if they don’t realize it.

AI will drive efficiencies to your customers where they are becoming reliant upon whatever technology is within their ecosystem. Companies are learning how AI can make their software products more valuable to their customers.

Going back to your comment about preferring to run a services business rather than a product business, how do the required skills and abilities differ?

The services business is more transactional in nature. It’s more volume. You can create value through a different lens on the services side, because any services business is in professional services and it’s providing human capital. You need policies, procedures, and enablement for your consultants to thrive within a given customer. They need to feel supported, so there’s a high touch, high customer service aspect to it. You’re working with human capital, so you want to make those people feel valued.

That also drives how your customers and clients view Optimum and our competitors. It’s how you handle situations when things don’t go exactly according to plan with a particular consultant, They have lives. Things happen. They have families. A particular consultant might be going through something that doesn’t allow them to perform at their best, or they have issues where they can’t be on site.

While you are dealing with employee or consultant issues, you have to offer white glove service to clients. You make sure that the client understands that we will do everything we can to backfill someone who doesn’t work out. The onus is on a professional services company to have a system in place that supports your consultant so they can do the best job. They shouldn’t have to be worried about whether their expenses are going to get paid or payroll will be on time. Then, do they have a support system and mentors internally?

In comparison, on the software side, you are selling a multi-year, enterprise-wide data platform product. That sales cycle can take eight to 12 months. It’s very much a consensus-driven sale because you are touching multiple stakeholders within the healthcare system. You need to get the buy-in from the CIO, CFO, CMIO, and sometimes the CEO. There are multiple sales points.

The other side of it is delivery. Once you sell the deal, the difference is on the delivery of professional services. You are reliant on the human capital and their knowledge base.

On the technology or SaaS data platform side, you are reliant on the technology. That incorporates a wholly different set of challenges and people that you are working with. I’m not technical even though I started the business. I still have a great team over at Clearsense. When technical issues hit my desk, I don’t have an answer, and that’s a humbling experience. Whereas on the professional services side, I’ve been doing this so long that even if I don’t have all the right answers, I have a good idea of how we should overcome certain challenges within the business.

What factors will impact the company’s strategy and performance over the next few years?

Growing those emerging service lines. We have a history of great delivery on the EHR side of the house and we are proud of that. With Jason and me coming back, we are infusing a culture of celebrating our wins, us against the world, and driving the type of growth that Optimum had in the early days. We are demonstrating that through high quality work, great relationships, and accountability.

We are proud to have become an Elite ServiceNow partner in a short period of time, and we are excited about the growth of that business.

We earned Workday certified partnership late last year and we are in the infancy stage of kicking off that practice. We hired our first practice director. Workday’s presence in healthcare is similar to Epic’s back in the day, with great software. They are starting to verticalize their offerings, having specific healthcare-focused salespeople and enablement, and looking at healthcare differently than their financial services customers.

On the cloud side, we are an AWS certified partner and a Microsoft partner. We are building that capability, whether it’s moving your DR to the cloud or moving an Epic instance to the cloud. We did the first one with Baptist last year, and we’re touting that as a use case.

We will be able to cross-sell into a healthcare system with these multiple offerings, essentially becoming more of a digital transformation professional services organization than an EHR implementation company as we have historically been.

It’s important for us to make that transition and stay relevant in today’s ecosystem with the technologies that our customers are using. We want to be able to help them through the process of being successful with their implementation of those products. We need to give our message concisely, understand how each type of software impacts the other, and make ourselves a vendor of choice for our provider clients, a trusted partner, whether it’s Epic, Cerner, Workday, ServiceNow or cloud migration.

HIStalk Interviews Jason Brown, CEO, MRO

Jason Brown, MBA is CEO of MRO of Norristown, PA.

Tell me about yourself and the company.

I have been in the healthcare technology space for almost 20 years. I have been working at the intersection of providers, payers, rev cycle, value-based care, and payment integrity, with an eye toward solutions that help take cost out of the healthcare system, move data, drive interoperability, and support value-based care.

At MRO, we think of the business as driving clinical data exchange among providers, payers, patients, and other third-party requesters at scale and driving health care interoperability across the ecosystem.

Is the term “release of information” still valid?

The business started in a document management style release of information. That’s still a core part of what we do and will continue to be. As we look at it, we are expanding out from that platform and taking perhaps a wider view of the opportunity. That opportunity is, how you make clinical data available on time, every time, to the right, credentialed user? The minimum necessary information available in the purpose fit format. 

Digital and release of information is a component of that, but not necessarily the totality of that. It is our core DNA where the company started and is still a big part of what we do. We built off of that capability and solution set to do a number of other things, and we will continue to advance those capabilities.

How has the demand for data exchange changed as providers captured more data electronically?

That’s a big part of the thesis that the demand for clinical data, in addition to claims data or maybe in replacement of claims data, continues to grow at a fast clip. The healthcare system places the burden on hospitals and providers to manage that clinical data and make sure that it gets to the right user, even though it sits in a bunch of different formats all over the place. 

As we see demand growing and complexity of data growing, there’s a great opportunity to be that middleware in between, partnering with providers, payers, other third parties — it could be pharmaceutical companies or patients themselves as legal requesters — to make sure that the minimum necessary data can get to the right place in the right format. On time, every time.

Life sciences companies seem to be the highest-profile data consumers, to the point that companies and provider groups have made a business of selling them data. How is that market progressing?

It is in an early stage.The appetite and demand from the pharma companies, life science companies, probably outstrips the supply or the ability to satisfy that data today. But there’s a lot of strides in interoperability, commercial models, etc. that is increasingly spinning up opportunities to be able to meet that demand, to do that in a secure way, do that in a way that is beneficial to the providers to allow them to participate in some of the economics, and then to make sure that we are ultimately helping to use the data that we have available to create the right type of pharmaceutical solutions for patients.

It’s early innings for sure, but that market has a long runway in front of it in terms of opportunities as we are able to meet that demand from life sciences companies.

What about data related to valued-based care, quality management, and care management?

I would say that is more mature than the life sciences market, but probably moving slower than all of us would hope. Part of the gating issue or pacing issue on more value-based care adoption is having that clinical data exchange between providers and payers. As you start to see a lot of the push and pull there, it is most acute in situations where there is some sort of value-based care relationship, where the provider needs to share data with the payer and vice versa so that they can both be successful in those risk-based relationships. 

That’s an area that has picked up a lot of traction for us over the last couple of years, but that market still is mid-innings. We would love to see it grow a lot faster, and I think it’s great for the overall healthcare system as well. As we enable more high fidelity, low latency, longitudinal clinical data to be available, I think you’ll see a step-function increase in value-based care arrangements, because both parties will feel that they can be successful in those relationships.

Does provider data still need a lot of cleanup and transformation to be understandable by the outside world?

That is certainly still the case. Strides have been made for sure. How you normalize standardized data, and in some cases tokenize it, to make it usable on the other end is still a big part of the healthcare value chain. Our solution set and capabilities is all about data extraction, digitization, ingestion, normalization, and standardization, and then you draw insights and intelligence from that. To make it useful, so that you can get it to whomever is requesting it in a format that they can consume it and have that data in a way that can drive the downstream insights and actions that you want to be able to power.

How is the market for patient registries that have been created or endorsed by professional and specialty societies?

That continues to be a very active market. It picked up a lot of traction over last 10 or 15 years. We have seen the evolution from value-based care type measures and quality reporting to now getting into some of the things we talked about earlier, which drive bigger clinical quality opportunities and opportunities with life sciences and pharma. That market is active and continuing to advance and innovate because they are sitting on large corpus of clinical data and deep clinical insights around certain specialties. Now they are looking at things in addition to their legacy work in value-based care around more quality stuff and partnering with life sciences firms in real-world data and real-world evidence.

Do you see company opportunities from using AI?

We are certainly digging into it now, looking at ways to leverage it across our entire book of business. We are actively developing a couple of AI solutions to power and automate parts of our workflow today that allow us to do more faster around quality insights, etc. We have big efforts around that. 

The other side of that coin is that of the vendors a company works with, all of them are developing AI solutions. We are actively working to evaluate those and understand how to move those into our workflows and into how we do things, whether that’s Microsoft Copilot, solutions from our telephony vendors, and even to back office systems such as HR and Salesforce. They all have different AI capabilities. 

We think it’s going to touch every part of our organization, not just the stuff that we can deliver to our clients and solutions that we can build, but also how we work with our vendors and automate different parts of our company. We are excited about that and are actively pursuing various initiatives right now. We have a lot of experience in different aspects of creating, running, and selling businesses in healthcare.

Is the business environment improving overall?

I think that the market is getting better and starting to normalize. People are a little bit more bullish about where the rate environment is going to be. We are heading into an election, and in any election cycle, healthcare tends to be on the ballot in some shape, form, or fashion. We keep an eye on all those things from a macro perspective. 

For our business more specifically, the tailwinds continue to be quite strong, as the demand for clinical data continues to grow at a pretty exceptional rate. That’s driven by a whole host of things, not the least of which is demographic factors. Ten thousand people age into Medicare every day, and a third or more of those go into Medicare Advantage. That’s a big tailwind for our business. Value-based care is big tailwind for our business. Demand for clinical data from sophisticated requestors, like life sciences, continues to be a tailwind for our business.  

Macro environment notwithstanding, we like all the trend lines of the need for clinical data to make healthcare decisions, treat patients, and drive better insights. We think that this is a long-term trend that will go unabated for at least a couple of decades.

What impact do you expect to see from the Change Healthcare cyberattack in terms of financing, healthcare policy, and antitrust concerns?

I’ll start with the last one because that will probably be the biggest. We now see where Change, United, and Optum touch every part of the healthcare system. This situation exposed the fragility of some of that and showed how connected some of these pieces are. Greater thought needs so be given to those aspects.

If you’re a provider, you have to think about who has your data and who you are connecting with. How do you make sure, as a provider or payer, that they have the highest standards of security, probably beyond HITRUST? We at MRO pride ourselves that we have been delivering secure, compliant data for 20-plus years, and we understand the sensitivity of that. Heightening those standards will increase. Every provider and payer will take a closer look, not that they weren’t before.

I also think about diversification, making sure that you don’t have all your eggs in one basket. That will have implications in how both providers and payers think about deploying technology and vendors. 

What are the key parts of the company’s near-term strategy?

We are in the early innings of a digital transformation. We want to continue to deploy technology across every part of our business. That will be a big part of our strategy.  We need to continue our client centricity and make sure that we are widening and deepening our relationships with our clients. We operate in a multi -sided network and need to make sure that we continue to deliver value to all sides of that network to continue to drive network effects across our business model.