HIStalk Interviews David Lareau, CEO, Medicomp Systems

David Lareau is CEO of Medicomp Systems of Chantilly, VA.

Tell me about yourself and the company.

I’ve been with Medicomp about 20 years and CEO for 10. Medicomp’s core business is connecting all of the clinical information and data that is in an EHR, whether as terminology codes or free text, and making diagnostic sense of it, either for the providers at the point of care or for people reviewing the record for diagnostic relevancy, which is important now with Medicare Advantage and value-based care. We’ve been building this for 45 years. It seems that the industry is moving in the direction of not just trying to paid for transactions and coding them, but getting paid for caring for patients effectively and proving that it was done. It’s an exciting time for us.

Doctors say they are burned out from keystroke overload and entering data that doesn’t contribute to patient care. How might that situation improve?

There are a couple of ways to go about it. If you approach the EHR like a burden, as most of them are now, you’re just trying to isolate the clinician from the EHR. Ambient AI is a play in that space, saying that we’ll just listen to what’s going on in the room, and then maybe at the end, we’ll tell you or a reviewer that you have to meet these quality measures and your documentation might not be sufficient to pass a Medicare audit. Capture stuff at the point of care, get it coded as best you can, but don’t really use the EHR as a tool for the clinician. Just try to isolate the clinician from the usability of the system.

Or, you try to put the information in front of the clinician, at the time they need it, for the patient and the condition or multiple conditions that they are dealing with. Here are the clinical quality measures that apply. You’ve met the documentation requirements. You have all the information properly done. Then present them what they need, when they need it, so that the EHR becomes a data repository, not a repository of text and other stuff that has to be dealt with after the fact. If you can’t do that, if you just keep popping up stuff that’s not clinically important when they are thinking clinically, they are going to get burned out and they will be frustrated. 

Value-based care, 21st Century Cures, and TEFCA have increased the need for what we think of as diagnostic interoperability. Either diagnostic interoperability between systems or diagnostic interoperability between the clinician and the system itself, saying, I’m dealing with this patient. They have these conditions. Show me what I need. Show me what reflects the way I think and work. Also, let me complete my work here and get on to the next patient.

One of the big things that people contact me about is Medicare Advantage. Medicare Advantage is not saving the government the money that they thought it would. There’s more and more people of the baby boom generation retiring and they are living longer with chronic conditions. We have to bend the cost curve down. How do we do that? One solution they’ve come up with is to take better care of the patients and their chronic conditions. CMS has said, we’re going to come and look at your records, and we want to see evidence that you have managed, evaluated, assessed, and treated every one of these conditions for which you’re claiming risk adjustment and risk adjustment solutions have been on. Make sure we get these things coded so that we get a higher risk adjustment factor for each patient. Fine, but are they really taking care of the patient? Does their documentation prove it?

That’s where we are seeing the most interest in what we do. At HIMSS, we will be promoting whether you have the processes and technology in place to protect yourself against Medicare Advantage fraud audits, because that’s about managing patient conditions, not just getting the diagnosis code right. We’re getting lots of interest on that from people who haven’t talked to us before.

It’s an exciting time to be in our industry. Some people get excited about AI, and other people poo-poo it. There’s a great place for it if you have good, clean, high fidelity data. Then it can empower these learning models and algorithms. The industry is in such a state of flux because of all that. W are just glad we are in the space we’re in.

Microsoft and Oracle are now deep into the healthcare application area via acquisition, and both companies have placed big bets on cloud and speech recognition. What changes do you excpect and how will they affect other companies?

There’s a great place for speech, text, and the technology. Natural language processing, NLP, which a lot of these approaches rely on, provides at best 75% to 85% data fidelity. Most of those systems are trying to find codes in text – SNOMED, ICD, CPT – through language models. They work pretty well, but when you are trying to get a full clinical picture of the patient, you need to turn all of that into computable data that you can filter diagnostically. That’s what enterprises are being asked to do. Manage these patients, especially under Medicare Advantage and value-based care, manage their chronic conditions, and show that you did it. A lot of the models are relying on reviewing that stuff after the fact to make sure we did it.

We were pretty excited a few years ago when we got approached by Emtelligent, which has a natural language processing engine. They wanted to add our concepts that are in our engine to the roster of vocabularies they looked at. I told them that we weren’t really interested in that, but if they could do a version of their engine that targets our vocabularies, then we can filter that stuff diagnostically. We can take the text record and say, show me what in this record applies to chronic renal failure versus diabetes and then pass that to algorithms that say if it looks like it’s documented adequately to pass a Medicare Advantage audit or not. There’s a real exciting mix of voice navigation and voice capture of information, but that still needs to be turned into data that is computable. We sit in the middle of all that.

How does the growth of ChatGPT and other AI tools impact company strategy?

The Gartner Hype Cycle says that it takes a while for hype to build, but I’ve never seen such an upward thrust in the hype cycle when ChatGPT came out from OpenAI. But there are valuable uses for this, because that kind of technology at its core does statistical analysis of data and pattern recognition. If the data is good and the information that you’re trying to process is best processed as data like they’re seeing now — images, MRIs, and mammograms in a consistent format – there’s an opportunity to get high fidelity data out of that and apply AI to it. 

Machine learning is valuable for remote patient monitoring, for patients who are willing to do it at home, for monitoring their hallmark findings for chronic conditions. Trying to support the clinician at the point of care is problematic, unless you just say that we’re going to use this stuff to capture all the information. We’re going to use voice, speech, and sound and turn it into something and then process after the fact to figure out if we have gaps in care. That whole framework for where this stuff is and where it fits now versus in 10 years, we are constantly looking at that.

We’ve decided for now that our place is to make it possible to take in all this information — whether it’s text or codes from these various terminologies and code sets — diagnostically organize it, and present it back to the user. Eventually that kind of information will be valuable for ChatGPT or other AI algorithms that then apply machine learning to detect patterns that would otherwise not be detectable. We are constantly looking at that. 

People used to call our stuff AI back in the 1980s, not the same way that people do now because we built it using physicians who determined what’s appropriate when you’re thinking of one diagnosis versus others. That’s valuable data. Getting data acquisition and being able to diagnostically filter it is important. We do that pretty well. If people can start applying AI and machine learning to the data to our data points, it will be valuable. We’re pretty excited about it.

ChatGPT provides a chatbot-like response to user input as an ongoing conversation. Will that affect the usual software design paradigm of static screens full of data entry fields and submit button at the bottom?

The chat paradigm is an evolving target. As a conversation proceeds, different things seem to become relevant. The challenge is that clinicians, not just doctors, are pretty highly trained users. They’re not like me going out on the internet and typing in a few searches to put together an itinerary for a three-day visit to Phoenix, I don’t know anything about Phoenix, never been there, so it’s a good tool for that.

When you’re dealing with a highly trained clinical user, and when you think about physicians — medical school, internship, residency, their experience – they are already pretty good at clinical pattern recognition. They would like systems to present to them what they know they need to do their work. That’s what we try to do.

ChatGPT does that by searching the internet to find things that the user is not familiar with and and constructs information for presentation. Our engine does that from a diagnostic framework, pulling all this stuff together. But the technology inside things like ChatGPT will be more useful to the clinician when they’re dealing with conditions that they are not familiar with. For example rare diseases. The National Organization of Rare Diseases has a list of 1,100 to 1,500, depending on how you count them. Rare diseases that in some cases, if detected early, will lead to much better outcomes. If missed, there’s not much you can do about it. You can’t really prompt every clinician to consider the symptoms, history, physical exams, and tests that are relevant for every diagnosis the patient might have.

But with artificial intelligence running in the background, you can present the things to the clinician that make it usable for 98 or 99% of all patients. An algorithm runs in the background that says, this patient might have this condition. If you want to see the hallmark findings of it, click here. If not, go about your work. They tell doctors in medical school that if they hear hoof beats, think horses, not zebras. For things like the zebras in medicine, AI and machine learning could be valuable.

Medicomp has made few announcements of executive changes, acquisitions, or funding, which usually dominates the headlines of other companies. How does that position the company in a challenging economic environment?

People have a tendency to chase the latest hot thing. If you guess right, great. But if you guess wrong and you give away equity or control, you can no longer focus on what the core business is or the core value that you bring. We’ve been clear from the beginning that we wanted to focus on providing a tool that presented information to clinicians, the way they were trained and the way they need it. 

To do that, you need patient capital. You can’t chase quarterly results. You have to approach your people as the most powerful, valuable, and non-replaceable resource in the company, because when you’re creating software and intellectual property, turnover kills you. Change of focus changes or ownership kills you. People say, we’re such and such and it’s in our DNA. I always say to them, yes, until you get a new CEO, and then who knows what’s going to happen? 

We’ve been consistent in what we’re trying to do. We’ve never gone into debt. We don’t chase the latest thing. We’ve always thought it was going to be critical at some point in this industry to move away from tracking transactions to get paid to tracking conditions to get better outcomes. Our engine was built to do that. We’ve been able to retain that focus and get enough people interested in using our stuff so that we had the revenue to stay on track and we had the opportunity to continue to our core engine and all the mappings as the industry changed. Then, adapt for what we needed to for our core mission, which is diagnostically connecting data and presenting it and tools for documenting it, if people want to use our documentation tools.

Changes are fine if you really need to change your focus, vision, or mission. Peter Goltra set one out for us a long time ago and we’ve been able to stay with it. We’ve been pretty happy with that. It has also allowed us to keep the people we need to adapt to things like Meaningful Use, 21st Century Cures, ECQMs, quality control measures, and TEFCA interoperability. Figure out what you’re doing, get really good at it, and stay at it until something tells you you’re doing the wrong thing. So far, we’ve been fortunate that we seem to have made the right big choices whenever we needed to.

What elements will be important in the company’s strategy over the next few years?

We think the healthcare IT industry is on a path to realizing that the clinical record of a patient, regardless of where it resides, should be computable data that will power analytics, AI, and machine learning. The challenge is going to be filtering that data and presenting it to the various people who need it and meeting all the requirements that are being forced down on the providers by all kinds of things. Home healthcare has a set. Hospitals have a set. Ambulatory has a set. 

We think that over the next three to four years, we will see an increasing move and realization that the important thing is caring for the patient using AI machine learning, and other techniques for identifying people in a population who are at risk. But you still have to somehow deliver the care for each of those conditions, one patient at a time. The industry is coming to the realization that it would be much better for these health information technology systems if we had data, not just a bunch of stuff electronically stored. We are excited because of the realization in the industry that data is paramount to everything.

HIStalk Interviews Steve House, Managing Director, Baker Tilly US

Steve House is managing director of Baker Tilly US of Chicago, IL.

Tell me about yourself and the company.

I realized the other day that I have entered my 40th year in healthcare. I started back in the early 1980s as a biomedical engineer for Phillips Medical for a decade, and then GE for a decade. I did work for Aetna building ACOs and then Kaiser as a senior director of data. I’ve been around in different spaces around the healthcare environment for a while.

I joined Baker Tilly a year ago. I am a subject matter expert in healthcare. My official title is managing director. I go out and do a lot of strategic work for hospitals, doctors, insurance companies, things like that.

Baker Tilly is fundamentally a tax and audit firm that was started back in the 1930s. It has expanded into all kinds of areas. We have a digital division that does ERP implementation. We have a robust Oracle team. We have an EHR team that was an acquisition of Orchestrate Healthcare. We do strategy service line analysis. We do all types of financial, technical, and clinical sustainability type programs. It’s 6,600 people, almost a billion and a half dollars in revenue, so it is pretty good sized, I think about #9 on the overall consulting size list.

How has health system C-suite leadership changed its thinking about health IT?

It has been a pretty big change and it’s going to be bigger going forward. We have a big labor problem. You have technology like the EHR and work that augments it. That technology is great to have, but it can’t slow doctors down significantly. We have big shortages in primary care, internal medicine, and obviously mass shortages in nursing, so the technology needs to be enabling.

We went through a phase of nearly 20 years where we were getting a handle on the data and making sure that we made it interoperable. It’s not all the way there, but certainly all those things were factors. Now we have to put doctors and nurses in a cockpit of a jet fighter-like concept, where they get the data they need and can make quick, accurate decisions and move them forward. We are in the midst of that transition, and I think it’s absolutely necessary.

Will technology-enabled telehealth and virtual monitoring allow healthcare to become more scalable and then more affordable or more accessible?

Yes. I’m in charge of our hospital-at-home programs. Plenty of people are looking at programs like that, where you are distributing healthcare services differently, in which patients and caregivers become more engaged. You have tools, technologies, social determinants, and an ability to look at it in simplified media formats, like a mobile phone. Suddenly, some of the labor that you need for delivering healthcare services is going to come on behalf of patients and their caregivers themselves as they invest and get engaged in the process. That has the potential to give us the greatest improvement and maybe put us on a path where we can actually succeed in this.

How will patient perceptions of the healthcare system change as more and more physicians become employees of entities whose primary objective is profit?

It’s always going to come down to access first for patients. When you need the system, is it available to you? We have significant access problems because of labor issues. Physicians being employed is, on the face of it, OK as long as you don’t lose productivity and therefore reduce patient access to the system.

But there’s also the other factor, which is that around the world, cost and outcomes — outcomes being lifespan and quality of life — have significant patient incentives. If you’re going to employ doctors and you’re going to have an issue with access because of labor pool problems, the most important next thing you can do is to make sure patients are incentivized to help themselves. You’ve got to make it comfortable and possible for them to manage their own healthcare at some level, and they must be incentivized to do it. Otherwise, it will just become a growing burden cause of aging.

What will happen as ever-larger health systems and insurers encroach on each other’s turf?

A debate has been running in the areas that I travel around the United States about the difference between medical care and healthcare, healthcare being population health, preventative medicine, the things that we do in that category versus, medical care that hospitals and doctors are fundamentally trained to do. If the insurance companies creep into this space in a significant way, the question is, should we think about splitting healthcare and medical care?

In other words, are hospitals and doctors the best places to do preventative medicine, nutrition, counseling, fitness, and weight management? Or did insurance companies find a way to do that part themselves? They try to pay for it, although I don’t think it is always paid for it at a level it should be. But the bottom line is that as they creep in, hopefully they take their biggest incentive — which is reducing variability and outlying costs because people get sick quickly or they’re not maintaining their health — and address that issue directly. If they did that, the system would work better for the patients.

Is it reasonable to expect most people to monitor their own health and use wearables, or is that just a nice idea that will impact only the few people who are willing?

I saw a statistic recently that of all the people who have a gym membership in the United States, somewhere around 4.5% actually use it. I don’t think that’s an indicator that we have got it figured out. Not everybody has to go to the gym, but I was on a task force during COVID and we determined that the average 80-year-old has lost 80% of their lung capacity. That’s obviously a huge danger sign for people with respiratory viruses. The bottom line is no, we have not done a great job of it.

If you take a system like Singapore, they use HSAs, and if you maintain your health and you meet criteria for blood pressure and weight and things like that, many of the dollars that go into your HSA that you’ve saved automatically become your retirement fund, and you don’t pay taxes on it. Those folks over there using that type of system, and they’re not the only ones, do a tremendous job of maintaining their health and staying in shape because they really want to retire. It’s that simple.

What are the technical priorities of health systems?

There’s still a lot of work to be done on the EHR side. Integration work needs to be done to finalize systems. We talk sometimes about a post-EHR implementation world. I don’t think we’re there yet. You have to go from gathering data, stewarding it, and placing governance around it to actually making it more usable. That’s the next phase and hospitals are looking at that.

The other side of healthcare is whether CFOs, CEOs, CMOs, et cetera have enough information to understand how to compete effectively in their own markets. It is still competitive marketing. Competition in healthcare is good for all of us because it drives better and lower costs. We must do a lot better job on financial reporting and cost accounting. We must do better on issues surrounding the data that we provide people so they can make better decisions in their markets.

What parts of health system digital innovation will stick?

Anything that can allow a patient to make a good decision when they need healthcare. If you’re at the mall, start to feel sick, and don’t know what it is, is there’s a kiosk there that gets you good information or provides contact with somebody who can answer your question on whether you should go home and take an NSAID or go to a hospital urgent care? We still haven’t gotten that figured out and we need to. On the patient engagement side, it’s making information available to patients so that they know how to make routine decisions. It’s all online, but not as functionally usable for patients as it needs to be.

As someone who ran for Congress, what do you expect to see from a political standpoint that will make US healthcare different in 10 years?

The one thing that you get when you are in Congress, or are running for Congress, is that there are 10 lobbyists for every member of Congress on the healthcare side. Political will is butting up against the lobbying process that goes on.

There’s a lot of things that should change, including how we manage PBMs, what safe harbor was intended to be back in the 1980s when it was passed, to how we pay for it. Even the fact that Medicare itself is both a payer and a regulator, and when you’re a payer and a regulator, that’s a disconnected process structure and it should change.

Will it change? We’re sitting at 20 or 21% of GDP. A point will come where if it doesn’t change one way or the other, the system is going to break. Some people want single payer, some people want more competition. I’m not a fan of the single-payer idea. I don’t think that’s going to work. But the bottom line is that if something doesn’t change soon, the sheer weight of the cost is going to become a problem that breaks healthcare down.

What factors will be important to the company and the US health system in general over the next few years?

I think it’s process change culture. There’s a lot of cultural issues in healthcare. The first question I ask any healthcare executive these days is, how is your culture? Are you capable of changing? Have you imagined a different environment? Do you have the information and reporting to give you enough decision-making capability?

Some organizations in healthcare have spent a decade or more just training their own leadership on how to make decisions and do it quickly. Healthcare needs to get faster, a lot faster, on the diagnosis side. A lot faster on the change management side. A lot faster on the decision-making side. That’s probably the area where we need to do the most work. Baker Tilly, as a strategic consultant and someone who does operational work, is focused on those areas.

After spending so long in healthcare in my career, I cannot wait to see this next phase, where data use rather than data aggregation and interoperability becomes our priority. What we can do with tools, devices, and modern concepts of how doctors will interact. The average doctor has 16 minutes to spend with their patient, and 11.3 minutes of that is used to input and take data out of an EHR. That’s not an equation that works in the long run. I have confidence that we’re going to see massive quantities of new technology and ideas come up to help solve that problem.

HIStalk Interviews Sachin Agrawal, CEO, EVisit

Sachin Agrawal, MSc is CEO of EVisit of Mesa, AZ.

Tell me about yourself and the company.

I’ve been in healthcare consulting and software for 20 years, always focused on the enterprise needs of hospitals and health systems in areas such as revenue cycle, physician network alignment, quality and safety, et cetera. I joined this business about six or seven months ago and took the CEO seat on January 1.

We are network-agnostic virtual care operating platform, primarily for large operators of physician networks and all the professionals that surround them. Typically hospitals and health systems and sometimes significant category leaders in other healthcare delivery categories, but mainly focused on the underpinnings of operating virtual care for these big healthcare delivery orgs.

How would you describe the virtual health technology marketplace?

It is asymmetric in terms of how I’ve seen other HCIT markets operating. It was forced upon everybody, but from the perspective of providers, it was forced upon them for obvious reasons. But it  not one that evolved from the critical foundational needs that hospitals and health systems have. 

As a result, a lot of health systems are picking their heads up, now that we are a few years out from the onset of the pandemic, and saying that they were forced to drive a modality that has been disruptive to their core operations rather than additive in all the ways that they need to be, given the economic climate. I was surprised by that as an outsider. I understood the needs of the providers well, but as an outsider from virtual care coming in, I was surprised by how much of the evolution of the market, from an intelligence perspective, has remained at the surface level despite the tremendous utilization that we saw the past few years.

Providers didn’t have a choice about implementing virtual visits as the pandemic started, but some brought in telehealth companies that use their own medical staff. How are heath systems valuing telehealth’s value to their brand or as it relates to their other services?

This is a head-scratcher for me. It’s puzzling to have seen hospitals either promote the utilization of those networks or let those virtual-first networks promulgate and post up in their back yards. That goes everything that I’ve learned about what complex healthcare delivery organizations are trying to do, in terms of raising the bar on quality and safety, balancing fee-for-service reimbursement with value-based reimbursement, looking at network leakage and network integrity, and things like that.

The common denominator across all those topics is that hospitals and health systems have been focused on tightening their networks, clinical integration, physician practice alignment, and increasing M&A to employ clinicians. I look back on that and it’s puzzling, because in a lot of ways, it’s the antithesis of all those things.

Hospitals and health systems are picking their heads up and saying, this is not aligned with the Quadruple Aim. We need to do something about it in the medium to long term, but we also have to figure out how to engage with those networks in an appropriate manner in the short term, because  going cold turkey is challenging in this labor environment and in this cost environment. There’s a tough needle to thread for healthcare delivery organizations. They are talking to us all the time about how to thread that needle.

How has the patient and provider experience changed as telehealth has moved from a quickly implemented solution to a permanent strategy?

The impetus during the pandemic was to take what was inherently meant to be a brick and mortar set of clinical protocols and a brick and mortar operation and just virtualize it. I’m quite explicit about painting the difference between virtual and digital care. Virtualizing care is what we just talked about — what organizations had to do. Now the industry is at its inception of the next chapter, which is to digitize aspects of care that they otherwise didn’t have the time to think about – design, change management, organizational buy-in, and things like that. That impacts how service lines themselves in a world where you can be digital first. It impacts who’s doing what in terms of top-of-license activities versus bottom-of-license activities. It impacts where people fit.

I can’t tell you how many stories I’ve heard about the pandemic when clinicians were still going into their offices, obviously socially distanced, and doing virtual visits out of the office. That’s not what the promise of virtual care was meant to be. Virtual care itself needs to go through this digital evolution while obviously honoring the systems, processes, and workflows that are in place, many of which are focused on clinical satisfaction, safety, and things like that. I don’t think there needs to be a revolution, but a thoughtful evolution that we’re just at the beginning of now that we’re picking our heads up post pandemic.

How do virtual care needs vary by specialty?

Significantly. I’m excited to see the data around providers leveraging their own networks and clinical protocols in a virtual way to drive similar, if not better, quality and safety outcomes et cetera. It’s great to see the early data on that. What’s needed going forward is both the complexity and the opportunity of going from virtual care to a digital evolution as use cases expand. 

As you go from urgent and primary care up the ladder to things with higher acuity and higher complexity, there could be device dependencies. There could be wearable dependencies. There could be group consultation needs and things like that. Importantly, you need to go from just a provider-to-patient relationship to potentially many providers per patient relationships, or many providers to many providers type relationships to drive complex consultations. That ecosystem, in terms of the need to create connectivity and to do that process and service line that I’m talking about, is going to be underpinning unlocking additional value from virtual care efforts.

What are some telehealth best practices that can help physicians work at the top of their license, such as pre-visit chats and triage?

That is part of an important broader question around what we can do to alleviate the burnout issue and the turnover that happens, which then impacts the high cost of recruiting, credentialing, and privileging clinicians to get back on the front lines. I’m reminded of a story of a customer who is the middle of digital reengineering as opposed to just virtualizing brick-and-mortar care. They are one of the more progressive institutions that I know of in the country, a Top 15 health system. They measure very carefully evening pajama time, where clinicians come home after  busy day, spend time with their families, and then most likely after hours after kids are down and settled in, they are logging right back into the EHR and doing complex charting. It’s because they had this backlog as they went about their visits throughout the day.

This is a critical piece when it comes to the top-of-license question. Pulmonologists didn’t go to school for decades to sit at home in their pajamas doing charting. This could be impacted on the front end through the intake process, the virtual triage process, and the asynchronous process where patients can assume more ownership. It should happen throughout the process as well, in terms of removing the barriers to documentation and charting. Then on the back end, the integration into the leviathan health systems,  power health systems like EHRs and revenue cycle. 

I think of it as the underlying need for integration throughout the process — beginning, middle, and end — to drive down things like evening pajama time. This institution would tell you that, as they have seen a drop in that based on digital re-engineering, they can directly tie that to a drop in turnover and therefore in recruitment and backfilling costs. It’s a KPI that they are looking at carefully, which is the promise of digital as opposed to sticking to your brick-and-mortar workflow and hoping for the best.

What do you expect to happen with telehealth when the public health emergency ends on May 11 and rules and payment policies go back to the early 2020 world?

It has significant implications. There’s a reason why pre-pandemic, the system was largely averse to some sort of a national credentialing or privileging approach, or even a cross-state credentialing privileging approach. First and foremost, we’re probably going to go back to life as we knew it before the pandemic from that perspective. That puts a significant accountability right back onto health systems to do credentialing in multiple states and cross-state privileging and things like that, which is a huge lift. They are already dealing with significant resource turnover. Just keeping up with the credentialing and privileging activities in their home state is drowning them. I think we are going to see a consolidation of where providers are able to practice virtual care. The other thing this will highlight is the need for those higher-acuity use cases that you are talking about.

Even within state borders, we’re going to see a greater separation of access to care. This is all driven by social determinants of health, access to specialists and subspecialists. Health systems will have an accountability. They’re going to have these key resources largely aligned with them, the subspecialists, that they need to find a way to liberate their time to cover a broader swath of a population even within a state. It’s going to beg the critical questions of how to re-engineer our processes to digitize that so that we can have our most important resources go further at the top of their license.

What changes do you expect to see in the next few years that will affect the company and the industry?

We have set up our company’s strategy to align directly with where we think the industry is going. I’ve been around the block in healthcare and I’ve seen platform categories come up over time. Usually these platforms are filling a critical void that exists between the core hospital systems, some of which I’ve mentioned — scheduling, EHR, revenue cycle, and digital front door if that comes into maturity. There’s a gap between what those core systems do and how to re-engineer care or to drive the efficiencies and to drive quality and safety standards up.

For the industry, as the dust settles on a pure outsource model to virtual networks and things like that, and there’s increased focus on how to we assume command and control of this as a health system, the industry will need a platform layer. I’ve talked to many CIOs and CMIOs in the past six months, and two of them from Top 10 health systems have described this as a need for a middleware to integrate in and out of the core systems, to author workflow, and to ensure that those workflows are being set up for the right people to do the jobs at the top of their licenses.

That’s a complex set of needs that needs a dedicated approach. That market will have plenty of room for participants, because the needs that it addresses are going to be significant. Of course we at EVisit are setting up our strategy to be one of the emerging leaders in what we believe is going to be a really exciting category in healthcare delivery.

HIStalk Interviews Adam McMullin, CEO, AvaSure

Adam McMullin, MBA is CEO of AvaSure of Belmont, MI.

Tell me about yourself and the company.

I’m thankful that I found my way into healthcare in 2006. I had worked around the US and the globe helping companies operate more efficiently by adopting technology. That was intellectually interesting. Getting into healthcare changed my life. That connection to the mission and how you can impact and help care teams and patients helped me find a sixth gear.

Before I got into healthcare, all I knew about healthcare was that a nurse agreed to marry me. It’s an odd coincidence that many of the businesses and teams that I have been involved in a focused around serving nurses with clinically-led and technology-enabled solutions.

AvaSure is the leader in acute virtual care. We are in about 1,000 hospitals, including all of the Top 10 US health systems, one-third of the magnet hospitals, and 70 academic medical centers. We help our customers adopt virtual care to get better outcomes at a lower cost.

What are the clinical and business benefits?

That strong ROI was one of the things that attracted me to AvaSure. The ability to both operate demonstrably more efficiently while having proven clinical outcomes was to a level I hadn’t seen. AvaSure pioneered the tele-sitter market. About 20% of patients have a clinical need for observation, but only 10% or less actually get an observer, which is a person physically sitting in the room with the patient. The data on the performance of the in-room observers is not very strong.

We can take 16 of those observers and monitor them in a virtual care center. We have over 120 studies as to why that improves results, such as reducing falls or harm. That is an ROI around using your team more efficiently during a labor crisis and getting better outcomes. Once you have adopted that, you have also put in the fundamentals of your virtual care infrastructure. That allows you to move into other areas such as virtual nursing, which is seeing a lot of interest.

What is a typical profile of an observer and what is their job like?

In a virtual care center, we have the virtual observers, and increasingly, virtual nurses. The virtual observers usually have a clinical background, where they were providing a significant amount of documentation around the types of patients being observed and what they are seeing in the room. If you look at sitting, there was virtually no documentation. The great catches that we get daily are around preventing falls, because they have clinical insight and can often determine that a step was missed. We have unfortunately found situations where visitors or family members are giving substances to a patient that they shouldn’t be getting, or that they are concealing a weapon. They are doing a lot of things by observing those patients. We are 15% nurses and growing. We work to ensure that those virtual sitters, and increasingly virtual nurses, are integrated well into the rest of the care team.

How are hospitals using the system to improve employee safety?

We unfortunately have had a significant increase across the nation in behavioral health issues. Patients often first present in the ED, where you don’t have the history. We are seeing all sorts of things, whether that’s aggression against a caregiver or elopement, where patients or just take off when they’re not supposed to. By having a virtual observer, we’re able to notify the care team so that they can intervene, call for help, or call for security if necessary.

Are the cameras recording at all times?

That’s a really important point. None of the video is recorded. Otherwise, you would have to have patient consent. The video is being observed in real time and trained observers are doing the job to make sure that they are appropriately monitoring the patients.

Are observers screened or trained to manage the psychology of seeing patients in their most intimate and sometimes unfortunate moments?

That brings to mind a couple of things. We guide hospitals as they are hiring observers to look for people who have clinical experience. It’s a great role where you can have a outsized clinical impact, especially if you’re at a point in your career where you don’t want to be on the floor as much.

Gay Landstrom, the chief nurse of Trinity Health –which credits tele-sitting with saving $22 million per year – told a story at our company meeting about a patient who was nearing end of life. This was during COVID, when there was no additional nurse to be in there to be with that patient. The observer worked it out with their supervisor so they could be one-on-one with that patient. They talked to them at this incredibly intimate moment and then ended up singing to them as they unfortunately and sadly passed. That story really connected what we are doing to the mission.

I’ve heard story after story. I was recently at the VA in North Dallas and there was a virtual sitter who got very attached to the patients she was observing, because you have clear two-way audio. It got to the point that she was bringing treats and brownies. There’s a pretty deep connection because these virtual sitting sessions can go on for days. You need to make sure that you have a high quality connection.

Do observers and patients have a lot of verbal interaction, or is it mostly observers asking patients how they are doing or giving instructions?

Oftentimes there are also redirects. One of the reasons that patients fall is that they need to go to the bathroom and don’t want to call someone to help them. If the observer sees someone with high fall risk who is about to get out of bed, they can redirect them. They can summon the care team, let the nurse know, and let the patient know that help is on the way. Other times the patient might need help with something that is non-clinical, and they can take that need off the care team, which cuts down on the number of times the patient has to engage their clinical team.

As you move into virtual nursing, which is focused on either continuous observation — for example, things like avoiding patient demise and keeping patients out of the ICU — or episodic admissions and discharges. If you’re doing a discharge, the unit is right next to the bed and you’re doing a lot of that discharge documentation and training. That’s a deep engagement between the virtual clinical team member and the patient.

Do observers have access to any of the hospital’s clinical systems for observation or data entry?

Our solution is a purpose-built, high quality, highly reliable, high level of quality of service, audio, video, either mobile or mounted device, plus a very scalable backend technology. For example, we monitor 80 hospitals for Trinity out of two centers. When we talk about integrating with other devices, we integrate with the EMR. You can get into your EMR and you can launch the setting, so you can see both documentation and have the audio-video connection. We integrate out to the clinical communication and collaboration space so that you can appropriately route information to the right caregiver. The cameras are high enough fidelity that you can actually read the monitors in the room, and if there are other key alerts, we can bring those into the system as well.

Once the technology is in place and services have started, who is involved on the hospital side?

You want to make sure that the change management is done with the care team that is actually on the units. We have some best practices to make sure that there is great connectivity and that we facilitate building trust between the virtual care center and those who are caring for the patients. Those in the virtual care center are obviously there ongoing.

We as a company provide 24×7 support for the solution so that we can make sure that you have the quality of service when you are delivering care or observing these patients with a critical need. We think a lot, from the technology side, about Day 2. After you go live, how do you make sure that this is well supported and that we are monitoring the health of the devices and the technology?

Does virtual nursing offer a way for nurses to continue their clinical careers without the punishing physical demands?

I was with a customer last week and we were talking about this. They call them their wisdom workers. In nursing, there’s something called the complexity experience gap. The complexity or acuity of patients has gone up, and as nurses have left the workforce, they are disproportionately the most experienced nurses. You are backfilling them with newer nurses who may have had less clinical training during the pandemic. Using your more experienced nurses in a virtual care center is of extremely high interest. It creates a second set of eyes as a way to better support your new nurses, travel nurses, and foreign nurses.

We’ve even had situations where nurses have suffered a physical disability, but they still want to contribute. Getting them engaged in a virtual care center, where they can be working with patients, supporting patients, and working with care teams, is a phenomenal way to make sure that their wisdom isn’t lost to our healthcare system

Are you seeing creative uses of your system that you didn’t anticipate?

We are seeing a tremendous amount of experimentation with virtual nursing, whereas virtual sitting is a well established use of virtual care in hospitals. People are running new pilots around virtual nursing to test wound care, respiratory therapy, and monitoring patients to keep them out of the ICU. They have put our devices in the hallways to have an extra set of eyes where there’s elopement risk. We do see a fair amount of creativity once you have high fidelity audio and video system with mobile units and units that are wired fully into the room.

What is the company’s strategy going forward?

We are finding a tremendous amount of interest in virtual care, so we are continuing to invest significantly there. As we do that, we are focused on a few things. First, that we continue to make sure that our technology integrates really well with the rest of the technology environment. We’ve unfortunately seen care teams underserved with systems are standalone or not well integrated, and we’ve bulked up in that area.

Second, and this is a bit of an overused term, is artificial intelligence. What that means in our market is computer vision and noticing more about what’s happening in the room. We don’t want to take a care team member out of the chain. We want to augment care team members. But with computer vision, we are seeing success and noticing more about what’s happening in the environment. We know if the patient is in the room or if they are about to leave the room. As we continue to invest in that technology, you can imagine that there are myriad things that we will be understanding, such as an IV bag that is about to be empty or that a tube has been pulled.

We will continue to augment the data layer. As you look in care environments, they are manually run. There’s a lack of data to understand how are we performing, what’s working, and how can we do better. Being able to provide real-time data and visibility into the performance of care units has been highly valued by our customers and we will continue to do more there.

We started with sitting, and now there’s a tremendous focus on nursing, We’ve also seen pharmacists and physicians using the technology. I’ll give you an example. We are working with a micro hospital that wants virtual nursing. They also want a centralized way to bring the specialists into the care team. It allows you to get the right talent to the right place at the right time, improve financials, and get better outcomes.

This is the most energized I’ve ever been in a role. That is because of the opportunity to help hospitals with the staffing crisis, the financial challenges they face, in such a meaningful way. The VA in North Dallas freed up 51 FTEs, so they are able to serve more of our nation’s vets. Being on the forefront of virtual care and acute care has been incredibly exciting. We are making a significant investment into the clinical research that goes along with this so that we can partner with our customers as we work together to pioneer how virtual care can play a role in helping health systems operate effectively going forward.

HIStalk Interviews Eric Ly, CEO, KarmaCheck

Eric Ly,  PhD, MS is co-founder and CEO of KarmaCheck of San Francisco, CA. He was a co-founder and the founding CTO of LinkedIn.

Tell me about yourself and the company.

I am a technology entrepreneur. I have worked on B2B software for multiple decades. I was one of the co-founders of LinkedIn. What got me interested in background screenings and verifications was that I was interested in something like a blue checkmark that would verify the information contained on LinkedIn profiles. That led me to the background screening industry, where I saw an opportunity to bring efficiencies and transform the way that background screenings and verifications get done.

You’ve mentioned the possibility of allowing people to store verified credentials in a digital wallet. How do you see the company being involved in that?

That’s a vision that we are working towards. If we are able to provide a wallet of credentials to professionals in the future, those credentials that are verified can essentially be persistent. When they go for new opportunities, that information is mostly there already. That speeds up the process of applying and getting job opportunities, both for candidates themselves as well as for employers. They don’t have to go and check many of those facts again.

Certainly there is information that needs to be updated with recent changes, but that opens up a world where the onboarding process can be more efficient for both sides. As we are moving towards the world where there is a more flexible and contingent workforce, the need and the value that provides is going to be become even greater.

It would make sense that LinkedIn user identities would require verification, especially now that we are seeing LinkedIn scammers pretending to be both employees and employers. Do you think that will happen?

That’s an interesting scenario. LinkedIn has been successful in amassing the professional information and histories of professionals all across the world. There can be a layer on top of that that provides verification of the  information that has been entered by those individuals. We are creating value by bringing truth so that the information that is associated with those profiles — whether they are on LinkedIn or elsewhere, let’s say on a job site — can be trusted so that when employers are looking at candidates, they will know that the information about the backgrounds of those candidates is confirmed.

The Department of Justice recently announced that thousands of people purchased phony nursing educational credentials, and some number of those folks presumably ended up obtaining licenses and caring for patients. We’ve also seen examples of nurses who harmed patients intentionally in hospitals that declined to prosecute or publicize them, allowing them to take jobs with new hospitals and continue their crimes. What kind of analysis or AI review could detect these issues?

Those are some interesting cases. In healthcare, here’s an example of where verifying someone’s credentials and their background is especially important, because we are talking about life and death for patients that healthcare providers affect. It’s especially important that the backgrounds of clinicians are verified. Beyond verifying current credentials, which is a complicated and complex stack already, skill competency tests could be run to ensure that the individuals have the expertise and knowledge that they need to do their job.

Something we have seen recently becoming more of a problem is verifying the identity of a particular candidate. If it’s possible to hire someone in the place of a clinician without ever meeting them in person, there is also an increased chance of the identity of that individual being falsified as well. ID verification technologies that can be used not only to confirm someone’s background, but to confirm that that background actually belongs to the individual that is being placed on an assignment.

The US has low unemployment and a significant percentage of citizens who have been convicted of a felony, suggesting that employers are either unaware or unconcerned about their criminal history. How would hiring decisions change if finding criminal records at local, state, and federal levels became easy and inexpensive?

Numerous surveys have found that at any given time, 25% to 40% of people have falsified their backgrounds. That’s pretty consistent across the board, whether it’s on an online platform or from a resume. Knowing where the falsification happened becomes an important point.

In this historically low unemployment situation, there might be the temptation to bypass some of these checks in the name of bringing more people on board, placing them, and so forth. That puts the employer or the staffing company at risk, because if something goes wrong, that carries a pretty heavy liability. In a field like healthcare, we are talking about life and death situations, so it’s not a light topic.

Because of the complexities that are involved in doing credentialing and meet compliance, this is an area and opportunity where technology can help. If those processes, as complex as they are, can be made more efficient and perhaps more cost effective, the reason to skip, overlook, or miss some of the infractions or violations that happen don’t have to happen as much. Companies and employers can still protect themselves while going through these compliance processes just as much as they should in more normal times.

How much inefficiency in provider credentialing could be eliminated by technology?

We are entering into a new world in healthcare and the staffing of healthcare. The general trend is that the scale and the velocity at which placements are occurring is speeding up. Hospitals and staffing companies have had to manage their staff at a faster pace than they ever had to before. Based on this backdrop of complicated credentialing needs, it becomes an unmanageable situation. The challenge is even greater when you have costs going up.

Technology generally helps to deliver scale and to deliver efficiency, so there are certainly opportunities for technology to be applied in these kinds of situations to help increase efficiency. That translates into is operating efficiencies and lower costs for the facilities.

That scalability might provide the opportunity to assemble a deep candidate profile that includes social media posts, credit reports, driving, records, online photos or reviews, and any number of information items that aren’t directly related to being hired. Will we see a tension between what is possible versus what is fair or reasonable?

There has been a lot of recent talk about AI and the application of AI. It enables any user to sift through more and more information to catch information that might help enlighten the background of a clinician, for example. The ability to look at more information, to learn more about the candidate, ensures that a qualified candidate gets placed, such that problems and liabilities are reduced. There is ever more information out there, and technology is a tool to help look through that ever-increasing amount of information.

What healthcare opportunities will the company explore in the next few years?

For an industry like healthcare that has maybe traditionally been slower to adopt technology, there are some great opportunities to take a look at making operations more efficient and cost effective. The main reason for doing any of this is to deliver better patient care, which everybody wants. In doing that and evaluating technologies, my recommendation is to not necessarily take a look at point solutions, but instead to have a holistic sense of the technologies that will deliver value to an organization, how it fits into processes and workflows, and how existing workflows can be changed a little to create significant improvements in operational efficiency. To take a higher-level strategic look at how technology can be deployed within an organization would be helpful for the healthcare industry.

Innovation is definitely happening within technology to specifically serve the healthcare sector. From a standpoint of cost savings and delivering better patient care, some good answers are starting to emerge.

HIStalk Interviews Angie Franks, CEO, About

Angie Franks is CEO of About of St. Paul, MN.

Tell me about yourself and the company.

I’ve been in healthcare technology for 33 years, so this is definitely my passion. I have spent the last six years with About Healthcare, formerly Central Logic. We match the demand for acute and post-acute services with the optimal setting of care to get patients to the best place for the care that they need.

How do EHRs fall short in care coordination as health systems expand their range of services and geographic coverage?

EMRs do many things well. But when you move patients across settings of care, or need to optimize the resources inside of your health system by pulling together different silos and different systems, there’s a lot of data that’s not in the EMR that becomes important and instrumental for making decisions around hospital operations and then executing on that. The EMR is more suited for capturing specific data about a patient, ordering tests, getting those results back, and then billing the insurance company.

When you are making decisions about where a patient should go for the care that they need, how to get them there, choosing the best physician, and then executing on those logistics, you are pulling from data that is not in the EMR. You need information that is in a lot of systems. What we see is that hospitals have lots of silos. They don’t work well as a system of care when it comes to the operations and the logistics. That’s where we focus, which involves connecting to, talking with, and interoperating with the EMR as well as a bunch of other systems.

The data inside of an EMR is impressive, especially when you think about the clinical data and all the work that organizations like Epic can do with disease and tracking all of this clinical information. When you look at it from an operational lens and a growth or a strategy lens, none of these EMRs capture and track this data in a way that is useful to strategy and operations. As a result, many health system leaders don’t look at information even though it could change how they operate as a business. That’s a real benefit of looking at your operations differently than how you look at clinical pathways and the billing systems. You get data out of these tools that inform decisions that you make as a health system executive team that have a impact on your bottom line. Data is an important area of focus for us over the long term.

Bed management and bed visibility became important during the pandemic. Will that have a permanent impact on health system operations?

One of the things that the pandemic showed is how silos create bottlenecks in the organization that prevent patients from getting access to the care that they need. Getting somebody out of the acute bed and getting them to a post-acute setting by doing that electronically and in interoperability setting instead of creating a bottleneck for patients who were trying to get in the front door and into a bed of a particular health system. Those bottlenecks exist all over our care delivery system and impact access to care.

We have gained a lot more visibility into the bottlenecks. Health system EDs were overrun during the pandemic and they couldn’t service all those patients, but maybe a hospital down the street had capacity, but nobody knew about it. Even when we put the USS Comfort and 1,100 beds in the harbor inside of New York City, we placed only 107 patients there. It wasn’t because there wasn’t demand for all of the beds. It was because there wasn’t an ability to access them, to communicate and efficiently see what was available, and then match the patient and move them. That speaks to the need for more interoperability in our healthcare IT ecosystem. We have a long way to go.

How well are health systems operating transfer centers and how do they fit into their business strategy?

It is an important front door for health systems. Acute settings have three entry points — the emergency department, scheduled procedures such as the operating room, and patient transfers. Patient transfers are least known and understood. 

A lot of health system leaders and executives may not have spent much time thinking about access points and access channels. They have business development teams and people who are responsible. It’s almost like a sales channel, but putting in place a conscious strategy and an infrastructure to capture more of the demand that is inside of the geographic service area that a health system serves and that net new patient demand for that hospital system. Those are lucrative patients, and every health system wants to capture more market share and then keep those patients inside of their network.

It is competitive for those patients. When you have an optimally functioning transfer center, you capture more of that demand. You impact your top line with revenue and your bottom line with improved margins. It is predictable. You can start achieving an ROI quickly if you invest the time. It’s not a technology implementation. Technology is important for enabling consistency and execution of a business process, but it is changing the way a health system operates and changing the way they utilize all of their resources for matching that patient demand with the right setting of care. If you just defer your front door to the ED, you pretty much get whoever walks in the door at whatever facility they show up at.

Do patients and physicians agree with a health system’s definition and approach to what they call “patient leakage?”

There will always be an amount of leakage. There are appropriate times where the patient is in a setting of care and they need to be somewhere else, which results in a transfer. They need a higher level of service or acuity. That could show up on a report as leakage. You had the patient, then you lost them. They leaked and they went to another system. Some amount of leakage will always happen and that is appropriate.

Hospital operators need to focus on when there is leakage that didn’t need to be. A patient comes into your emergency department, you offer those services, you have capacity, but it was hard to get that patient moved out of the ED into the right bed. It was easier for that ED doc to call their buddy, who is a cardiologist down the road, and move that patient into a different health system. That’s a costly leakage problem, and it happens every day.

It is costly to let patients just walk out the door instead of helping coordinate follow-on services or referrals to a specialist as they take that next step in their care journey. When you leave it up to the patient to just figure it out, it’s not a great experience for the patient, but it also results in a lot of leakage for the health system. It is an important metric to look at, calculate, and focus on, because it has implications to revenue and operationally and it can be a bad experience for the patients as well.

How are health systems changing their business model to address new competitors, telehealth, and new generations of consumers who would rather use urgent care?

What I see health systems doing over the last couple of years, and the pandemic was instrumental in this, is talking about operating as one system of care. How they use all of their capabilities to care for the patients in the community, and do that more efficiently and in a more streamlined manner. The conversations that are happening are really good.

I could give you many examples of what health systems are focusing on. We help them think about the acute and the post-acute patients. That is a  small population of their overall patients and the communities that they serve, but hospitals and health systems have an enormous amount of competition for those healthy patients and the outpatient visits, whether it’s CVS, One Medical, or even Dollar General in some smaller communities. The margin erosion and the patient attrition for services that were maybe more easily captured in the past is an issue, and that revenue has to be replaced some other way.

Health systems are figuring out their population health strategies, figuring out their access channels how to deliver service not only to the patients, but to their referring community. Managing those referring networks as an important growth channel is a different way of thinking. I’m seeing more conversations about that today than I have in the past.

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

I see our company continuing to focus on solving this problem and helping health systems operate as one system of care, doing that by connecting their silos and disconnected systems into a streamlined process so that they can operate more effectively. It is a passion of mine. For everybody who works here at our company, this is what we jump out of bed to do every day. As I’ve gotten older, I see my parents needing to access healthcare services in different ways, and it sure gives you a lens on the importance and the mission orientation of the work that we do. We are going to continue focusing on this. It’s a big problem, and we are in the early innings of the game.

HIStalk Interviews Laura McCrary, CEO, KONZA

Laura McCrary, EdD is president and CEO of the Kansas Health Information Network and KONZA National Network.

Tell me about yourself and the company.

The KONZA National Network was started in 2010 as part of the HITECH and the American Recovery and Reinvestment Act funding that was made available to each of the states. KONZA is a 501(c)(3) not-for-profit organization that is incorporated in Kansas under the name of the Kansas Health Information Network — KONZA is actually a DBA. The organization provides services not only in Kansas, but across the nation. The KONZA National Network provides health information exchange services as well as analytics services.

Kansas managed the process of establishing a health information exchange a little bit different from other states. That is relevant to the way that the KONZA National Network has developed. For example, Kansas didn’t stand up its own state-sponsored health information exchange like most other states did. Instead, Kansas established a process to certify the exchanges that did business in the state. Kansas didn’t give an allocation of state or federal funds to the health information exchanges. Instead, those funds went to the provider community to purchase interfaces and connect to the health information exchange. That was a key component of the development of KONZA and the health information exchange framework in Kansas. 

The state then established specific criteria that all of the exchanges that did business in Kansas had to meet. You had to run a viable business that had providers and payers paying for the services that you provided. It was a subscription model, and everybody paid.

Also, you had to participate in supporting public health. You had to be involved in building the public health infrastructure. It was a partnership. The HIEs all agreed to send data for electronic lab reporting, syndromic surveillance, and immunizations. Kansas was well prepared for the pandemic because we had been working on that for 10 years.

The other thing that was interesting is that Kansas said that all data that was brought into the exchange also needed to be provided to the patients through a personal health record. Early on, all of the health information exchange data was provided to patients at no cost. That allowed us to be one of the early participants in the Harvard Open Notes model, where all of the data that we had available in the exchange was provided to patients.

It was a very different and unique model of certifying exchanges. One piece that was important was that all the exchanges that did business in Kansas had to connect to each other. While we may have been competitive, we also had to cooperate. That was a basis for how we were able to spread this exchange across the country. We had a commitment to all of the things that I just mentioned because of the way the initial Kansas HIE infrastructure was set up.

What are the implications of creating a national network?

Most of your readers will be familiar with the QHIN model under TEFCA that is beginning to come into fruition. The QHIN model is the Qualified Health Information Network model, sponsored by ONC and The Sequoia Project. KONZA has applied to be a QHIN and is working through that process now with ONC and the RCE. That will be an important development in interoperability across our nation, because we will see a number of QHINs that will have responsibilities to connect to each other and share data to establish that nationwide context.

The fact that KONZA already does business with exchanges in 11 states gives us an opportunity to be at the forefront of that. We run exchanges in Connecticut, New Jersey, Georgia, South Carolina, Mississippi, Louisiana, the Dallas-Fort Worth area, and obviously Kansas and Missouri. We also support an exchange in Northern California. That gives us a pretty broad national scope in terms of leveraging the QHIN model. We are excited about the possibilities of what the future looks like for health information exchange as we move forward into the later part of 2023 and 2024 and we have the QHIN model operational.

What challenges remain to giving patients the full benefit of interoperability?

There will continue to be issues with interoperability until we resolve the issues around standards in data sharing, the actual semantic interoperability of using a variety of different code sets. For example, it is still difficult to make sure that labs are being mapped properly to the LOINC codes and that SNOMED codes are being used properly. We often find that there’s still a lot of challenges in being able to do all of the proper coding and mapping.

We work hard at KONZA on data quality. We are part of the NCQA Data Aggregator Validation, or DAV project, where we take all of our practices and hospitals through DAV accreditation with NCQA to ensure that they have the highest quality of data that can be delivered. We check those things, like has the hospital mapped their labs properly to the LOINC codes? And are we seeing the proper procedure codes coming through? Are we seeing duplicates in data?

All of these things are still challenges for us. The data is still messy, so it’s important for us to focus on data quality. We have a couple of key vendors that are instrumental in helping us do that. But it is a core focus for us on data quality. 

If you can’t get the data quality in the place that you need it to be, you are not going to be able to provide a complete and correct longitudinal record at the point of care for a patient. If a patient shows up in an emergency room and the doctor doesn’t know who he or she is, the doctor is dependent upon getting a longitudinal medical record from the health information exchanged to make sure that the physician knows all of the information about the patient before they begin providing care.

We are getting closer. Let me say that I feel enthusiastic about the future of health information exchange, particularly with the QHIN model that is coming into place. I think that we will see continued improvements in the data quality and the data completeness. But it’s still a work in progress.

The early days of RHIOs involved creating centrally administered platforms that left providers to figure out how to connect. How has that transitioned into a more services-oriented approach?

Health information exchanges flew under the radar from about 2010, when they were funded, up until about 2019 and early 2020 when the pandemic hit. Then it became clear to the entire nation that the health information exchanges had been developing products and services using the data that they were receiving through the health information exchange and aggregating that data and being able to turn it into meaningful information that could help to inform public health and others regarding the progress of the pandemic as well as the vaccination status of the population. Health information exchange quietly built that capacity over the years. 

KONZA has 4,500 organizations that contribute data into the KONZA enterprise data warehouse. When we need to aggregate data across the nation and be able to track disease surveillance, the health information exchanges were well prepared to serve as that public health data utility to step into that space and provide information. For example, they provided COVID registries to the state of Kansas before they had the ability to get a registry set up. We set one up quickly for the state of Kansas in about 30 days, because we were already tracking the data and had it coming in for health information exchange purposes.

KONZA also has the ability to aggregate data across practices and across states to be able to look at quality measures. One of the things that KONZA does is calculate and compute quality measures, not only for physicians and hospitals, but across populations, whether it’s an independent physician association, an accountable care organization, or a Medicaid health plan that needs to be able to look at how they’re doing across their Medicaid population.

The health information exchanges have built that capacity and have been certified as having the highest quality data that’s available. It can be counted upon by payers, providers, and others as it relates to quality metrics. We see imminently on the  horizon that quality measures will not just be calculated out of an individual EHR system. They will be calculated across all of the locations where the patient received care. That way, you have a holistic view of how a hospital or a physician practice is actually doing in providing quality care to a patient across the patient’s entire care team, as opposed to just looking at what happened at their facility.

How will you participate in clinical research?

We regularly get requests for de-identified data to be able to be used for clinical research. When KONZA, executes agreements with our participants, we have a secondary data use agreements that allows the data to be able to be used for purposes that advance medicine. Now, it can’t be used for purposes that would be used for marketing or for financial gain. But for clinical research that actually improves the practice of medicine, we have a team of doctors that meets to review each request that comes in to us. 

In the past years, we have focused on delivering data individually as each request came in. But we are building a product, which is being tested with a children’s hospital, that will provide de-identified data to the researchers at a hospital so that they can look into being able to use the data themselves, configure the data, and manage the actual research without us having to be involved. We are excited about our pilot project. I’m hesitant to name the children’s hospital, but it’s around how chemotherapy has affected children’s cardiovascular systems over time. Because we gather longitudinal records over time, we can often look across an individual’s life. We have, in many cases, 15 or 20 years worth of data that we can look at. Researchers are going to be able to take the data, model it themselves, and start using it for some amazing research that we haven’t been able to do before.

What strategies or tactics do you think will be important for the organization over the next three or four years?

Our work with the payer community is becoming more important. Many of your readers are all too familiar with payers having to send individuals out to pull records or asking practices or hospitals to send medical records so they can do their quality reporting around HEDIS and risk adjustment. That business is starting to become less and less because these records are all digitized. There is no reason to go out and make a copy of a medical record on the copy machine, ask someone to fax a medical record in, or have individuals spend time and precious resources doing things that are no longer going to be necessary as all of these records have become digitized. 

More and more, we find that our business is moving towards providing data to the payers so that they can meet their quality goals around HEDIS and risk adjustment, which is one of the reasons that we are so focused on having the highest quality of data. We want to make sure that the data that we provide to providers is correct and complete, and to our payer customers is correct and complete. That is becoming an increased focus for us, to spend time working with payers, understanding the data that they need, the timeframes that they need it in, the format that they need it in, and to be able to deliver that payers. Our goal ultimately is that we can provide the products and services to the provider community in return for the data that we receive from them. We can provide that to the payers and eventually be able to reduce the overall cost to providers in our community to be involved in a health information exchange to a minimal amount. The providers are contributing their data, and we see that as being extremely valuable and we want to continue to build upon that perspective.

HIStalk Interviews Michael O’Neil, CEO, Get Well

Michael O’Neil, JD, MBA is founder and CEO of Get Well of Bethesda, MD.

Tell me about yourself and the company.

I started GetWellNetwork 22 years ago following a personal cancer experience while I was in school getting a JD/MBA degree at Georgetown. I started the company with a simple mission to make it better for the next person. I had spent way too much time going through surgeries, chemotherapy, and coming in and out of hospital beds and clinics. I thought that these amazing people who were delivering my clinical care needed some help in delivering the kind of patient and family experience that could enhance not only my attitude, but also my outcome. I started the company to help hospitals leverage technology to engage patients and families more effectively in their care, and in turn, help clinicians and improve outcomes.

The original concept was somewhat limited, focusing on in-room patient entertainment and education. How did you broaden the company’s reach to include everything from pre-acute to post-care and even remote monitoring?

I look at this as two acts to a play with an intermission in the middle. Act I was long, 15 years of trying to improve a two-day, four-day or 12-day hospital stay. We met a patient at admission and we said goodbye to them at discharge. We we were in many ways proud of transforming the hospital experience at the point of care for the patient, family, and nurse.

A bit before COVID – and COVID certainly accelerated this — we began to invest, both in organic R&D and in some acquisitions. We knew that the impact that we could have on both our customers and people and their health journey, which had become nine or 10 million people in a year. Their journey was not just that two, four or 12 days – it was a lifelong journey, a 30-day journey, a surgery, or what have you.

We had this intermission period where we doubled down on investing in R&D. We bought a couple of companies and that helped us accelerate to build Act II for the last 18 to 24 months. That involves enterprise engagement, navigation, and retention. We have a chance to help organizations wrap their digital arms around either members or patients at scale, but do it with intimacy that is required in healthcare. We are excited about today and what lies ahead.

Patient engagement seemed to align well with value-based care, which has had perhaps less impact than everybody expected on health systems, and now the imperative involves patient recruitment and retention. What are the primary motivators of health systems to improve patient engagement?

It’s actually straightforward , and there is a triple purpose on this. The industry is littered with tiny niche consumer engagement solutions. It doesn’t have many true platforms at scale. When we talk to health systems, payers, and managed care organizations, we are talking about what we would call Get Well Anywhere. The value proposition is threefold. They need to drive their business because these organizations have been through the grinder the last three years. If you can’t claim, stand behind, and share risk in the ability of your consumer engagement solutions to drive business, we don’t think you can do a lot of business in today’s health system world.

Number One is these AI-driven outreach tools that we have now, the ability to navigate people back into their primary care, to help them navigate into a mammogram or a care gap or something like that. It is driving direct revenue when it comes to fee-for-service organizations. But a lot of times, those same organizations also have value-based pockets. They have taken on full inpatient risk in a certain market.

The powerful thing is that the same platform, the same workflows, the same what we call Get Well Navigators — who have been trained to help people in vulnerable moments leverage technology and then pick them up when they can — these same things work to make sure that we are guiding patients to the appropriate and oftentimes lower-cost point of care, or doing self-care. The number one value prop and number one driver of people investing in this now is business, whether you are in fee-for-service or you’re in risk.

The second reason, and I don’t say this lightly, is that loyalty and patient love are more important than ever. We have an internal Slack channel at Get Well called Call Patient Love, and all day long our navigators are streaming comments from our thousands of patients every day who have interacted with one of our navigators, who interacted with a nurse, or who interacted with a physician who has touched them in a certain way. It matters. This kind of patient loyalty and patient love is the second piece. It’s a little softer in its ROI approach but it’s not unimportant.

The third thing is that workforce challenges are everywhere. This isn’t a temporary thing. This has been going on for a long time. How can you leverage the power of the patient and their family caregivers to help drive efficiency of your incredibly precious workforce?

That is our three-part value prop. I will tell you pretty bluntly that we are driving at Number One. We are going at a lot of risk for this. If you have 800,000 dormant patients, we know we can convert them back to activated. They need care, and that care will also drive revenue. Let’s share in the risk of that. Let’s make sure they get the care they need. That allows us to then make other investments alongside of our partners in things that they want to do.

Insurers are making significant inroads into becoming providers, while providers are sometimes taking on the role of payvider. How does this affect your business?

On the payvider side, a lot of our large complex health systems have partnered fairly meaningfully and financially with local, regional or national payers. In those partnerships where they are taking on risk, they of course are terrific partners for us. We are doing a lot of innovative stuff. You are managing 12,000 mothers on Medicaid and you are responsible for their full cost, so we are running a Mothers on Medicaid navigation program that was a feature at the White House last December. We think there’s a way to really help these incredibly important people in our communities have the very best care and have a healthy pregnancy. In that case, you have an aligned payer and provider delivering great care and the solutions match that way.

In a world where you have payers who are starting to invest in direct care as you alluded to, they also need tools. You know from using your employer’s portals and digital tools that nobody uses them. The trust relationship and the navigation is light. We are partnering more and more these days with some folks on the managed care side, because we now have 20 years of data on when people are in this vulnerable spot, what are the interactions? How frequently should we be interacting with them? How can we recruit and hire local navigators who are in market who understand the communities, understand the local vernacular? How do you build trust on behalf of a health system or a payer? Those managed care companies have struggled for a long time with that, and we think we can help. We have shown some data to be able to help that as well.

How did your business change with the pandemic?

In all transparency — as you have built your entire organization around directness and transparency, which those of us who get to read it love — it was challenging. The most challenging thing for us was we lost touch with the clients that we work with day in, day out, month in, month out, quarter in, quarter out. We work closely with chief nurses, chief experience officers, CIOs, and nurse directors on an ortho unit that is doing a certain pathway for post-knee replacement patients and how they are going to navigate through their discharge. This is work that we do all the time. We have a lot of clinicians in the company. That changed. We had to figure out how to support them without being able to be with them, and that’s a difficult challenge.

On the other side, it tested the dynamism of our solutions and platforms. We gave a solution called GetWell Loop. It’s a library of 300 digital care plans. I was at a fellowship in Colorado when COVID broke out. When I got home, w4e met as a team. Within three weeks, we had built five COVID loops. We deployed them over the next six weeks in 200 command centers across the US at no cost to our provider partners. We ended up touching and helping over a million patients stay safe at home, and helped ER beds free up so they would stay available for the sickest people. It challenged folks to support our clinicians in a way that we are typically supporting them.

Thirdly, ironically enough, it gave us a little bit of room to double down on R&D and transformation. We contracted with this amazing firm in the UK to design a completely new consumer-grade UX that we just launched late last year. We built a BYOD version of our inpatient solution that we are deploying now across lots of hospitals without capital investment. We acquired a business that does AI outreach and navigation, which has been amazing.

We doubled down on our government investment. We spent quite a bit of time and resources on getting FedRAMP approval for our cloud-based solutions in the government. We do a lot of work across 70 or so VA medical centers and now we are able to bring our loops and our navigation stuff into those communities for our vets. That is a source of pride and drive for the company as well.

The interest in AI tools such as ChatGPT has been unprecedented. How will AI technology be applied to patient engagement?

We have a front row seat. We were admittedly a little bit slow on the organic R&D in AI. We just didn’t have the bandwidth to get ahead of it. We acquired a company whose foundation is in AI and chat. One of the elegant things that we liked about this was that it has an ability to interject AI and live chat simultaneously. You are building real-time profiles of patients and how they are interacting with the content and our people.

As an example, we are working on a large project in California, where we had close to a million dormant patients. We were given a file from their EHR company. They had not been in to see a primary care physician in over 18 months because of the pandemic. We used our AI to reach out to them. To give you a sense of this, you’re talking about 2.6 million AI-driven, text-based bidirectional interactions coupled with 40,000 supplemental live interactions from our navigators.

The good news is that we are seeing the AI work and people respond to it. But we also would tell you that the realization in healthcare is to think that this stuff will be done exclusively without people. We believe that human interactions in your biggest state of vulnerability will require people to make sure they are monitoring, looking, and attaching in highly personal, delicate, and intimate ways in times of need. We have combined AI with a high-touch approach as well. We are seeing some great results that we are excited about.

How do the areas of patient engagement and patient-reported outcome measures overlap?

This is where things get fairly complicated among the EHR and its capabilities; a large CRM platform and its capabilities; and tools, solutions and platforms like ours.

We are seeing that a large health system will often default to the large enterprise EHR or CRM. We don’t fight against those platforms at Get Well. We spend as much time on programs as we do on platforms, meaning that these platforms are only as good as highly discreet programs that help an individual or a micro population of people navigate through their incredibly individual journey.

It sounds cliché, but you had better be able to integrate into core EHRs in a deep, API-driven, and oftentimes more so these days, FHIR kind of fashion and have SMART apps and things like that. You had better be able to pick up on a broader campaign from a CRM outreach. But in our world, you had better be able to put on top of those two platforms some individualized and personalized programs. Because if not, we are going to see engagement rates just like we saw the portal for 20 years. That’s not good enough. People need help.

How does the company’s history of acquisitions and funding activities change with the current business environment?

It’s been crazy. At HLTH, the buzz wasn’t just patient engagement and health equity, but also the cash burn of companies that have spent a lot of money on marketing knowing that their solutions are fairly niche and are not scaled. I don’t envy being in that kind of startup, early stage, cash-burning mode.

Get Well was not an overnight success. This stuff takes a long time to get  right and to get to scale. But we are fortunate. We have a lot of customers. We have positive cash flow. We are able to invest our own money in things that we actually want to pursue. We will be working this year on an important youth mental health project in Mississippi. We can take our own money, which we actually make, and invest in things that we think are projects of purpose.

The funding environment has changed dramatically, literally over 90 days, because there was a lag. The private markets stayed relatively hot until August and September and then they started to cool. That has been a significant change.

As a company that has been around for a while that has some scale, these are opportunities for us. We are thinking about our strategy. We are thinking about how we might accelerate our own R&D efforts with other companies that might be willing and excited about partnering with us to do something bigger together versus smaller on our respective owns. We spend a bunch of time talking to the ecosystem and staying connected. Honestly, I’m rooting for all of them. Everyone that is doing good work in patient engagement means that somebody on the patient end is impacted.

I hope they all succeed, but they won’t. It’s tougher because there are fewer buyers out there, as health systems consolidate and become fewer and fewer prospects. It is difficult not only that there are so many vendors, but so few customers. It’s a double whammy for the small niche players. Fewer customers, and those fewer customers have a hard time adopting, integrating, and implementing tiny projects that don’t have the security measures and integration depth that these multi-billion dollar, multi-state organizations expect. You have pressure on that side to work with larger, more stable, more comprehensive solutions. Secondly, there’s a big movement at the CIO level to consolidate suppliers.They can’t manage 14 different consumer-facing tools or whatever.

This is not to say that I don’t believe in innovation. Our industry always needs people who have identified a pain point and are going after it in a creative, innovative, new way. However, these entrepreneurs need to spend as much time honing their business models as they are honing their elegant solutions, because too often these amazing solutions can’t get scale on the revenue side, and there’s not a lot of forgiveness out in the market right now for that.

What will be important to the company in the next three or four years?

One is what I will call Get Well Anywhere. That is, finding our way into relationships where we become that third core solution. You have an EHR, you’ve got a CRM, and you have an engagement, navigation, and retention platform with the depth, the credibility, and the security to make sure that they can deal with these two behemoth solutions while also having the rare ability to deliver digital intimacy that those big platforms lack. We want to find our way into more of these Get Well Anywhere partnerships that are large, where we are sharing risk, and where we can drive business, patient love, and workforce efficiency at scale. We are excited about the progress there.

The second thing for us is that we will continue our work and we are doubling down in the government space. We have had such success in impacting US veterans. We are doing more work these days as well in active duty military clinics and facilities. We are excited about the impact that consumer engagement and navigators can do with the folks that we cherish. We have 30 or 40 veterans on our  cohesive, amazing, and focused team. We are doubling down on their success to make sure that we can impact veterans in active duty military moving forward.

The third thing is that we have primarily been dealing with health systems for 20 years. There are school systems, payers, and other organizations that have a vested interest in engaging constituencies in their health. We need to get outside our comfort zone and help populations do food as medicine, navigating to treatments, and doing self-care. These are the kinds of things that give us great purpose and that we are excited about.

HIStalk Interviews Elad Benjamin, VP, Philips

Elad Benjamin, MBA is VP and business leader of clinical data services at Philips of Amsterdam, Netherlands.

Tell me about yourself and the company.

I run a business within Philips called Clinical Data Services. We are responsible for integrating and delivering acute patient data to physicians, nurses, and any other caregivers who require it. We also provide analysis of that data to help with clinical insights and improvement of care.

I have been in healthcare informatics for the past 25 years in various roles around medical imaging, medical devices, radiology, and AI. I’ve been both on the entrepreneur side, having formed a few startups of my own, and also now on the larger corporate side within Philips for the last three years.

What progress has been made and what challenges remain for health systems to connect their own internal systems?

We have made a lot of progress within certain niches. For example, the medical imaging niche has made a lot of progress in being able to move and communicate medical images with each other. The medical device niche has made a lot of progress, such as with products that we have developed, in integrating medical devices and the data that comes out of those devices.

A gap remains between those silos. If a healthcare enterprise wants a full picture of a patient across imaging, acute general care, lab and other areas, the integration of all that data into one view still remains a bit of a gap. EMRs fill some of that gap, but not all. We still have a ways to go in helping enterprises bridge the gap between those different care settings of patients.

How well is that information made actionable for those on the front lines of patient care?

For some information, we have a relatively robust set of alarms and alerts that can be provided to the care staff. The problem, and this is talked about a lot in the industry, is alarm fatigue. It’s hard to understand which alarms are more relevant than others, which alarms are actionable versus others. Over the past couple of years, we as a provider of solutions have embarked on not just creating an alarm and delivering it, but understanding the content of the alarm and delivering it only if it’s relevant and actionable.

We have been delivering smart alarms and alerts to the market for the last few years. They are not as simple as, “A patient has gone over a certain threshold, so let’s beep or let’s send an alarm.” We look at trends and a multitude of factors, and only if there is real patient degradation or a real actionable alert do we send something. We have made a big effort over the last couple of years, and will continue for the next few years, in moving from simple alarms to smart alarms that can reduce alarm fatigue and improve care. You are acting only on those alarms and alerts that need your attention as a caregiver.

Does AI play a role in that analysis?

It absolutely does. Today, rules and alarms are relatively rules based. They are not as complex. But we are beginning to explore AI-based rules, primarily for the purposes of prediction. 

You don’t necessarily need AI to understand what is happening at this exact moment with a patient because there are a lot of parameters that you can analyze in real time to say what’s happening. But if you want to predict something, even if the caregiver hasn’t seen anything or felt anything, a certain trend is leading the patient in a certain direction. For that, machine learning and AI tools are absolutely coming into play as we start analyzing millions of patient inputs to see patterns that allow us to make more accurate predictions.

Does the burden of manually entering clinical data remain, or has it moved mostly toward automatic data collection from medical devices?

That has been automated over the last couple of years. When we go in to our healthcare enterprises, there’s absolutely no manual work involved. Once we set up the system, all data is moved automatically from the devices into our system. It is automatically stored. It is sent automatically to whoever needs it. The whole process of large-scale data management, at least as it relates to our realm in clinical data services, has become automatic. No manual intervention is needed.

That trend is slowly taking over other care settings in the hospital as well. In the relatively near future, we won’t need caregivers to manually move data around. We will have systems that understand where a patient is and where the information regarding that patient needs to be delivered in that specific setting. The system will make that information available to the caregiver.

What are the technology implications of the COVID-driven change to move patient monitoring outside of the ICU and even outside the hospital?

Al the technologies that were very, very good inside the four walls of the hospital didn’t necessarily extend to the community or to the home. As those needs accentuated over the past couple of years, we need that connection. We’re getting there.The need is understood. 

Financial questions need to be answered about how those services get reimbursed and whether they are covered by private sources, insurance, or the hospital. These are not technical or clinical issues, but financial ecosystem questions that need to be resolved  to make that true, seamless link among clinic, home, and hospital. We’re not there yet, but we are putting a lot of resources into making that a seamless connection. It is understood that the connection is inevitable and it needs to happen. We just need to accelerate it.

We’ve moved from bold and possibly irrational predictions that AI would replace radiologists to viewing it as a helper. How do you see the role of AI in radiology and radiology informatics?

AI is here to stay and it is definitely helping radiologists be better in certain areas, whether it’s neurology, neuroradiology, or other aspects of radiology. A lot of research shows that radiology plus AI is better than radiology alone. I think that will continue.

As to bold statements that were made a few years ago that we won’t have radiologists, we are still far away from that being a reality. But we are getting closer and closer to where AI can be like a first-year resident. It can do some basic things. It has solid basic knowledge and it can help reduce some of the more menial, repetitive tasks and open up some time for radiologists or other senior physicians to do the more complicated tasks.

Can AI help healthcare amplify and extend services beyond the limits of physical buildings and hard-to-find clinicians?

I think so. That question also connects to providing care outside of the hospital environment. Not just AI, but smart medical type devices will allow us to provide care. You won’t necessarily have to go in somewhere to receive care. You might have a smart device that is able to get vital signs or early blood work and transmit that information so you can receive care remotely.  

Some of those things are happening at a small scale, but will become part of this changing ecosystem. Not all care will be delivered even in the same place physically as it is delivered today. Over the next decade, we are going to see a big change in that.

What are the most promising use cases for AI in healthcare?

I wish I had a crystal ball to know the most promising use case. But I can tell you that we see three main uses — clinical, operational, and financial. 

The clinical use case is the one that will benefit patients the most, but it’s the hardest to deliver at high quality because of all the challenges we’ve spoken about with data and data availability. It’s hard to diagnose people accurately and consistently. On the scale of value and difficulty, the clinical one provides tremendous value, but it’s hard to do.

Existing financial or operational AI tools are not necessarily as hard to deliver, but their value in terms of improving patient care is also reduced. They focus on making the operations of a hospital more efficient, which is great and important, but it’s a bit of a different way.

I don’t know which one will advance the fastest, but I really hope that we are on the cusp of seeing the breakout of clinical AI contribute in a meaningful way over the next few years. That will make the difference for patients in the future.

Healthcare’s move to the cloud provides new options for centralization and scalability and also brings big tech players into the industry. How will that develop?

You can divide healthcare’s moving to the cloud into two main implications. One is technological, in that hospitals no longer necessarily have to invest as much in their own IT infrastructure since they can rely on off-the-shelf, large-scale IT support. That’s a good thing. It helps reduce the overall cost of managing large, complex IT systems.

The second part involves the data. If you have the ability to not worry constantly about how much storage you are using, and it’s cheaper to do it besides, then you will start to amass this large quantity of data. Then the question is, what do we do with it? Because everything is connected, it comes back to AI and analyzing the data. We see more insights coming off of the data rather than what healthcare used to be, which was just delivering data from Point A to Point B and relying on the caregiver to understand the data, the context, and the next steps.

Where it is going is that we are not only delivery mechanisms of data, but we are also decision support tools. We are helping determine care pathways for patients and treatment protocols. That is the opportunity that some of these cloud technologies open up for us. Now that the data is more accessible, there’s a broader set of data to be looked at, and that opens up a lot of great opportunities.

What developments will be important to the company and the industry in the next few years?

At Philips, we continue along a few main paths. We have a strong imaging portfolio that includes software, hardware, and services that we will continue to develop. Alongside that, we have other connected care businesses that follow the patient along the different settings. We are working hard to integrate a lot of that into solutions that allow taking care of the patient across the entire continuum without having to necessarily throw data or pieces of information over the fence. The company will be investing to create that holistic view for our caregivers.

We are also deepening the technology that we use. We spoke a lot about AI over the last few minutes. We will continue to use deeper, more advanced technologies to move from retrospective or real-time to more predictive and decision support.

HIStalk Interviews Jaffer Traish, COO, Findhelp

Jaffer Traish is COO of Findhelp of Austin, TX.

Tell me about yourself and the company.

I’m the son of two parents who grew up in poverty. One parent lost two siblings due to food insecurity. At 15, I became a community organizer, working to improve the health of families living near old power plants. Over the years, I’ve worked in government, health IT, and advisory, My focus is on improving the health and wellness of the vulnerable. Our CEO also had many experiences that led him to found Aunt Bertha, now called Findhelp. He worked on streamlining benefit enrollment in state government and became the guardian of a relative who had a rare disease.

The mission of Findhelp has remained the same since founding, to connect all people in need to the programs that serve them with dignity and ease. We are focused on the social drivers of health, such as food, housing, transportation, and other human services. We work every day with communities and government to modernize the social safety net of health and human services by providing open, focused, and contracted social service networks and integrated software for healthcare plans, employers, education, government, and community organizations. We are seeing something interesting happen. Nearly 1 million new adults use the network every few weeks, and that’s humbling and sobering.

Our US healthcare model is an world outlier in being very much driven by profit. What are the challenges in creating a safety net and connecting people to it?

There remains enormous friction in the way people apply for benefits, determine their eligibility, and source post-acute care, social care, and placement. The social service sector and the post-acute care sectors are just catching up to the age of digitization and basic interoperability. It’s interesting to see the first White House Conference on Hunger in 50 years and some new investments, like broadband investments, that are showing some greater federal attention to the safety net. There are more than 240 bills in Congress right now with social care components and over 80 with health equity components, though still today, public policy is slow to address root causes of disparities. With a mostly private-funded safety net, it’s difficult to achieve that scale under our current program.

In terms of the role of government, there are waivers in 23 states with social care reimbursement elements. We believe that government can fund capacity of services, streamline enrollment, require reporting, and accelerate interoperability certification, though they should offer guidance to states on this work and not necessarily suggest paying vendors large sums of money as as solution to social drivers of health.

What is the effort involved in finding hundreds of thousands of programs and maintaining their information?

We call that team our human curation team. It’s hard work. Our team is on the phone every day talking to service providers across the country, validating important information such as the languages they support, eligibility rules, and sliding scale cost structures. We believe that providing individual seekers the dignity of being able to explore their own options is important in this country to empower individuals to find the best services. That information has to be as accurate as possible, as they don’t have the luxury of extra resources, and we want to build the best connections for them to those providers.

That team is our largest investment in the company. We believe that some degree of automation is important and can help us in that curation work, though we receive thousands of signals every day about how programs change and our team is responsible for reviewing, vetting, and processing that feedback. That’s a commitment that we have as a public benefit organization to serve the country and ensure that we make Findhelp.org a free service to the nation. 

The network is important. On top of the network, we provide, on the private sector side, the software and tools for care coordination to support connectivity between private industry and the social services sector.

We’ve seen a lot of non-profits engage with us because it helps them with their overall operations. Most folks don’t know, but we provide free case management tools to non-profits, and when they sign up with us for no fee, they have the ability to publish their appointment slots. They can run reports to show their funders how they are serving people. They can see who’s using search terms to find their organization. They can publish an eligibility screener so they can automatically respond to people to let them know whether they qualify for their service or not. They can even integrate referrals into their own non-profit system of record so they can continue working in their own workflows.

What is your business model?

Our business model is relatively simple. We didn’t want to take the approach of traditional health tech companies and charge user licensing or have a PMPM model because that restricts the number of helpers that can engage in this work and the number of people that can self navigate. Early on, we decided that we would have a simple annual subscription model to the software and to the network to integrate and embed into your own navigator workflows. That has been quite appealing to healthcare, government agencies, community colleges, and even large employers who have come to us to help their employees.

Each industry has their own drivers for why they sign up. Some, it’s financial. Some, it’s recidivism. Some, it’s clinical outcomes, student retention, and so forth. The broadness of the network appeal creates a network effect, and that’s why we are seeing somewhere around 50 new large systems join us every quarter right now.

What is the role of the health system that joins?

For our customers that have helpers — and this could be a social worker, a discharge planner, or a navigator of sorts — they are quite interested in assessing individuals for their social needs, generating outbound connections, referrals, or applications to the non-profit sector. Even ordering goods and services, which is something that has emerged in the last couple of years, like diapers or car seats for a new mom to leave the hospital on time. They are interested in building these connections and even funding and supporting some of the service delivery for those connections.

They are interested in tracking the service delivery outcomes and eventually marrying that information with their own clinical or cost information so that they can begin to study the impact of doing this work at scale within their populations. Integration is a key part of their vision. For example, our bi-directional referral integration with Epic’s Compass Rose is a big investment to bring smoother workflows to these tens of thousands of navigators.

What does that integration look like to an Epic user?

We’ve built four integrations with Epic to meet customers where they are in their investment into social care. The first is to give dignity to the population, and that is an integration with MyChart. That is where customers like Trinity Health have embedded their social care network directly into MyChart so people can self-navigate and self-refer to programs at scale. That’s tremendous, by giving people the dignity of access.

The next integration is bringing the network live as a SMART on FHIR application embedded into the care navigator’s workflows. With that integration, navigators can send referrals, process applications, and text and email program information to people who may not be ready for a referral and otherwise navigate the entire network.

There are advanced customers who want to leverage Epic Healthy Planet and Compass Rose to natively have the network living inside of the Epic tools. That’s where the integration is using APIs to allow helpers to directly surface information about programs and send referrals bi-directionally to the non-profits without ever needing to use our software.

How did your work change during the pandemic?

We saw over 100 healthcare organizations join us during the pandemic. We saw major EHR companies reach out to us to accelerate the development of this integration. We added around 4,000 COVID-19-specific support programs to the network during the pandemic. We saw significant volume increases around the country of people looking for help and of navigators using the network. We were up late at night for more than a year working hard to improve the system scaling as well as the software features to support such growth.

How does United Way’s 211 program integrate to support people who lack broadband access?

There are around 240 different 211s around the country. We think the work they have been doing is incredible over the years. Many of them operate call centers, and that’s the first place many people think to call when looking for a service. 

We view them as complementary to the work that we do in many communities. In fact, we collaborate with more than a dozen 211s around the country, and some of them are actually our customers. We see the potential for 211s to not only operate as hubs in communities, helping with care navigation, but also being able to collaborate on the program network and the quality of the program information, as we often both do that curation process in communities. I think there’s an evolution of the 211 model that we are seeing happen around the country.

KLAS has reviewed the small market of social determinants of health networks, in which Findhelp earned top scores. How do you see that market evolving?

We were doing this work 12 years ago, before the term “social determinants of health” was a buzzword. We called it “poverty alleviation.” There were around 15 companies in this space. Over the last 10 years, most of them were either acquired or closed up shop. 

It’s interesting because we see three key issues coming to light. The first is privacy. How do we ensure that individuals can control their private referral information and share it when they are ready and not force an oversharing model? The second issue is interoperability. Are we willing to make the investment as a company and integrate and interoperate with the right systems around the country? Third, how do we work with government? Do we enable government agencies that have helpers to do this same work, or do we depend on government funding to build infrastructure? Our approaches to those three have resonated with many industries, including healthcare. That’s what I would attribute our momentum to, alignment with those that are doing this work to those principles.

What developments do you expect to see over the next few years?

Software is only a small part of building bridges between healthcare and social care providers. Our most successful customers are in the community with us, building trust with the service providers, hiring community liaisons, and organizing coalitions. That is real network building. We are going to see a plethora of funding, and we must be mindful that we direct that funding as much as possible to capacity of these service providers, who are the ones doing the hardest work to serve our communities. That’s where we should keep our focus and attention, serving the service providers and the navigators that do this work every day.

HIStalk Interviews Patrice Wolfe, CEO, AGS Health

Patrice Wolfe, MBA is CEO of AGS Health of Washington, DC. This interview was focused on women as health IT executives.

Not to hit you with the hardest question first, but if you see a company whose executives and board members are nearly all white males, how do you convince them that they may have chosen unwisely?

No kidding, you’re asking the hardest question first. Maybe I’m just an optimist, but I like to believe that the best way to convince people is through performance and through results.

I was on the board of a large company recently and it was nine white men, mostly in their 70s, and two women. I had a hard time convincing the rest of the board that when we had open positions, we needed to be a little more open minded in terms of how wide we would set the aperture for the candidates for the roles. 

I’ve noticed that often when we do searches for senior positions — whether it’s a board position or an executive member of an operating team — all the search descriptions end up sounding like the person must have won a Nobel Peace Prize and walks on water, because we are trying to make the job sound as complete and as attractive as possible. Sometimes we create job descriptions where we’re ratcheting down the aperture so much that five people in the entire country can fit this job description.

When you are trying to drive diversity, you have to make sure you open that up a little bit. You have to let in people who might not be traditional candidates, and you have to be willing to take a chance. To me, the thing that has been the hardest is convincing people that the answer isn’t, “We’re going to hire the best person for the job.” Because the best person for the job often looks like a very traditional candidate, and that does not help us gain ground on diversity.

Is that because it’s comfortable to hire candidates who are like us, or is it the perception that those other candidates aren’t as qualified as they actually are? And would you see the same biases toward female candidates if the company leaders were mostly women?

There’s an element in this that we all gravitate towards people who are more like us. That’s human nature.

I don’t have enough experience with all-women leadership teams to know if that bias exists. There’s not enough N’s out there for me to have a good feel for the answer to that. If I look at my own leadership team, we’re about 50/50 in terms of male/female. That puts me in a great position where I don’t have to worry quite as much about gender diversity.

I’ll tell you what I am typically the most focused on — cultural fit. Is the candidate someone who can thrive in the culture that I’m trying to cultivate? That’s definitely not a gender thing.

I don’t think I have a perfect answer to your question. I’d love there to be more examples of women-only leadership teams out there so that we could tell if they suffer from the same bias.

Given the frequent importance of networking in getting hired, how does networking work differently for women than men?

This is such an interesting point. It’s something that I talk a lot about when I speak about gender diversity at the senior executive level.

The good news is that if you are hiring at the executive level, you are most likely at some point, maybe not initially, going to use an executive search firm. For me, that has always been a great way to meet people I don’t know.

But in terms of the networking element, no doubt the more networked you are, the more likely you are to get tapped for a wider range of opportunities from a career perspective. One of the things that women have struggled with is finding themselves in those situations that maximize networking. Are they invited to certain types of meetings? Are they included in a small group of leaders who might be attending what now are incredibly expensive conferences?

What I’ve seen over the years is that you have to almost make a deliberate effort to include women in these types of activities that end up being great networking opportunities. It has to be a deliberate action. It works well when it is tied to things like recognition of high-performance employees. If you do a good talent review in your organization every year, you can pinpoint those members of your employee base who are high potential. You can deliberately do things such as say, we’re going to earmark these people for attendance at a particular conference, or we’re going to earmark them for presentations to the board on a particular topic that they’re focused on. If you don’t do that stuff, those people lose out on the networking that might make them more well known as a candidate for an executive role.

How do men and women apply and interview for leadership jobs differently?

The Harvard Business Review published a study on this many years ago. I may not quote this exactly right, but I believe that the findings were that women would put themselves forward for a role if they fit 90% of the criteria for the job, whereas men would put themselves forward if they felt they met 60% of the criteria. There’s definitely a difference there, obviously in general, but I do think that this is challenging.

When I mentor women, I raise this point a lot. What’s the worst thing that could happen? You could be told no, you’re not qualified enough for the role. Too often, people might build up in their minds an outcome to putting yourself out there that is far more daunting than what really happens. Sometimes I think it helps just to get people to talk through, how could this play out? And are you OK with how this might play out? Why not try?

This is a general challenge that we have to deal with through mentoring women. Also, modeling the behavior that comes from saying, what the heck, I’ll give this a shot. Maybe it won’t work out, but I’ll probably learn something in the process, at least.

Bias sometimes exists against women who have current or future family obligations. Are the trends of remote work and increased work-life balance changing that?

This is a really interesting point, because so much has shifted generationally. I was guest lecturing at a Wharton Business School class a couple weeks ago in the healthcare track, and I had several interesting comments from the students. They were interactive, it was so fun.

One of the students, a woman, raised the point that nowadays men and women are particularly focused on work-life balance. There is more of an acknowledgement, with younger professionals, of the important rule of maintaining both a balance in your personal and professional life, but also maintaining a level of mental health wellness that people my age never really paid attention to. This woman was saying, what about men taking paternity leave and other types of family related time off? Isn’t that part of how we achieve some of this balance in the workplace?

That is exactly right. Younger professionals are more focused on work-life balance in general, and it’s not a gender issue. We are seeing men taking this seriously also. That’s an interesting thing, that some of this gender distinction is going away.

In terms of work from home, I do believe that the trend towards work from home has made it easier for women to take on roles of greater responsibility. I see this in India, where there traditionally has been a big drop-off in women in management roles, because once they start having children, many women have enormous pressure to not go back to work. Work from home in India has helped to shore up the growth of women in management roles in all kinds of industries. I’m fascinated by how the whole workforce dynamic has shifted with work from home.

What career advice would you give to a woman who is in a director or senior manager role and wants to move to VP or the C-suite?

If you want to get to the top echelon of an organization, it’s important that at some point in your career, you get experience managing P&L. Maybe you just manage a cost center, and maybe there’s no revenue attached to it. Too often, you see women working their way up the ranks in support functions, things like marketing or HR, where they don’t get an exposure to enough of the business side of the organization. Having the ability to run some type of operating unit inside a health system or a software company is an extremely important role, because it gives you exposure to a wide range of the key operating metrics for the organization that are important when people are assessing you for the very top of an organization. I don’t often see that as a focus for people’s career paths, and it’s important.

Always be intellectually curious. Raise your hand when something interesting is going on in your organization that you think you could learn from and that you could add value to. Be willing to step out of your comfort zone to show that you can make a difference in a way that’s maybe a little bit different than how you’ve traditionally been spending your time.

Those are great opportunities to expand your understanding of your organization, to expand your networking. You might work with different people than you’ve traditionally worked with. Also, to expand your knowledge of what you personally enjoy, because too often, we find ourselves down a path incrementally that maybe we’re not happy with.

It’s  important for women to find mentors and folks at senior levels who will support them throughout their career,. I’ve been fortunate to have people in my life like that. Actively searching out the men or the women in more senior roles in their organization who they admire or they think they can learn from, and actively build a relationship with those people, because they can be hugely helpful to you.

The last thing I would say  is to believe in yourself. Stand up for and pursue things that you’re interested in, because we are always our own best advocates and we deserve to be good advocates for ourselves. Having a level of confidence to do that is important.

HIStalk Interviews Matthew Condon, CEO, Bardavon Health Innovations

Matthew “Matt” Condon, JD, MBA is founder and CEO of Bardavon Health Innovations of Overland Park, KS.

Tell me about yourself and the company.

I’ve been in employer-driven musculoskeletal health for the  last two decades. I grew up in Iowa, went to grad school and law school, and got passionate about this space. I was fortunate post-law school to relocate to Kansas City, which was the home of Cerner. There’s a Cerner halo here in Kansas City and a lot of people, including the founders, were important to me in the early stages and helped guide me in my career.  

I have been on this journey for a couple of decades, building companies that were specifically aimed at supporting employers in how they optimize the musculoskeletal health of their employees. I’m really fortunate to have built a couple of companies here and I am proud and thankful to call Kansas City my home.

Bardavon was formed in 2014. It is absolute love of mine, intellectually. We partner with employers, or the carriers who represent them in some cases, to optimize the musculoskeletal health of their employees. This ranges from preventative through post-injury solutions that are offered in a hybrid manner at work, in the clinics, and at home. All coordinated, all collaborating, and all aimed specifically at improving the lives of the 60 to 80 million US workers that make up the labor workforce in this country.

Our biggest differentiating factor is that we have seen the spectrum move from all-in clinic to this digital-only focus, and I believe that we are the only people in this space that offer a truly hybrid approach. We have digital solutions that we incorporate, engage, and coordinate, but we also have a nationwide network of over 25,000 physical and occupational therapists that utilize our solutions in an integrated manner aimed at improving the health of the one patient-employee in front of them and the tens of thousands we serve on an annual basis.

How competitive or cooperative are you with the providers that contract with you?

They are partners and we are really proud of that. The first business I had was on the provider side, where I built a company and sold it to a publicly held company. That understanding of the provider realities, the environment that they work in, and what they are aimed at is important to who we are, and maybe why we bring such value to them. We partner with those providers. They get out of their EMR and into our platform for the patients that we send them from the employers that we work with, who want exceptional care for their injured employees.

It is double-sided marketplace, but one that I am proud of on both ends. We feel partner-focused. It is our job to get employers around the country the best healthcare for their injured employees. It is also our job to make that environment for the providers who are treating them efficient, clear and communicative, and collaborative so that they know what success looks like for their employers. They can aim at it and they are rewarded for achieving it.

We’ve seen MSK technology evolve from range-of-motion home exercise coaching that ran on consumer gaming systems and now to technology platforms that include apps and analytics. What is the best use of technology for MSK issues today?

Acuity levels drive the appropriateness of the solution that you put in place. But in the end, the in-person provider relationship experience has never been more important than it is now. Coordinating that with digital solutions that enhance it, especially as you get to a certain level of acuity, just makes sense, and it works. 

The provider community was maybe generally reluctant to engage with digital solutions, but now at least the 25,000 providers we partner with use it because they see that when it is added into their plans of care and added into their care experience for their patients, they are getting better outcomes.That is what those providers want, especially when they are rewarded for it with more referrals from those employers that are looking for that better experience.

All this digital solution application was thrust at the marketplace. Ironically and tragically, though, there weren’t a lot of innovative solutions provided for the American worker, that 60 to 80 million men and women that build our roads, build our buildings, fight our fires, and protect our streets. There’s a unique engagement environment for them. They are unique in that with regard to MSK, their job is the biggest risk factor to their health. No solutions were targeted specifically at them. We think that is a mistake and an opportunity that Bardavon is uniquely fulfilling.

Do employers see workers’ compensation as a problematic expense where providers may take advantage of them or bill for services whose value can’t be proven?

It’s all of that, and there is validity to all the reluctance to enter into this marketplace. Some of it is more structural. Workers’ compensation care — how we address and impact our associates that are hurt on the job — is siloed in a completely different and often disconnected part of the structure. It’s actually property and casualty that your workers’ comp comes under. Your trucks, your equipment, your property, and the workers’ comp injuries are housed in a different silo of the insurance industry. That has created an environment that historically had us treat these individuals as widgets and line items on Excel spreadsheets. 

Today’s reality is that we have this labor shortage and this massive need for these people to be healthy, happy, and productive at work. That has created an environment where the perspectives are evolving. That is tailwinds for us for sure, that employers and carriers are understanding that we have to reevaluate the way that we address this marketplace. They aren’t widgets and they aren’t line items, they are people and they carry with them functional issues that either do or don’t help them do their job effectively. Bardavon is leading in this solution set of providing that group with appropriate, effective tools that they can engage and utilize to improve their lives and improve their productivity and work culture as a result.

A lot of people are trying to solve MSK and workers’ compensation. The MSK health of the American worker has been historically neglected, but we feel that the evolution that needs to happen in the MSK space is best launched from workers’ comp. There’s a number of reasons that make it the most advantageous place to launch it, and we believe that that will happen and are excited about it.

You realized that your previous company, ARC Physical Therapy+, had reached a scale problem where you could only grow so much being tied to bricks-and-mortar operations. You also found that the insights available from data were more valuable than actually delivering the service. How did you apply that experience to Bardavon?

That’s exactly right. We went in with a belief in this unique way of addressing the marketplace, going to employers, building clear value propositions, and clearly aligning the incentives of the provider and the payer around the function of the patient. We believed that was the right thing to do. And as you indicated, we changed a marketplace because of it. We had employers change the way they helped their employees navigate the healthcare system to get access to our clinics for the data.

As I mentioned early on, I was fortunate that we built a great company and I was really proud of it. It was, in part, the founders of Cerner — Cliff and Neal a little, but Cliff in particular – who challenged me that we had a national business that we were choosing to operate locally, and shame on us that we were not thinking bigger. At that time, the world had changed. The cloud had come along, and housing those solutions within the bricks and mortar of the couple of dozen clinics that we owned didn’t change a national marketplace, it only changed a local one. 

We believed that we could evolve the company to no longer be beholden to the bricks and mortar, but to partner across the country with providers and payers that cared. And in so doing, not just change the health and healthcare experience of the employees, but find out which providers in every ZIP code of this country were healing patients in a way that was quantifiable and objective.

That is an exciting part of what we do today. We get stronger every day in knowing who is actually healing patients in a way that we can measure, not based on CPT codes or bills, but whether or not their patients are returning to a level of function. That is, I believe, the most transparent and beautiful reflection of healing in healthcare.

How much of the company’s success and ability to scale was driven by requiring providers to document patient progress in your own proprietary platform?

It is bi-directional. It’s not just that they are documenting and sending us the data. We are telling them at eval what success looks like for that employer, what success looks like for that employee who is injured, and what their functional job demands are. There is no guessing, there is clarity. Then we create this beautiful feedback loop that updates and gets better every second of the day about what providers are doing in other parts of the country with like patients with like return-to-work requirements, that are optimizing their outcomes and doing it efficiently and effectively.

All of that is a dream and a vision. Healthcare providers went to school with the hope that they would be in that environment. Most of them, or maybe all of them, got pushed into an environment that historically and traditionally didn’t facilitate that. We had to ask the providers to do something unique to get there. 

Asking them to get out of their EMR and into our platform is not easy. It’s incumbent upon us to make it as seamless and intuitive as possible, but more than that, it is incumbent upon us to make the providers believe that their dream of why they went to school is our dream. To create a system where good providers get more patients and benefit from that, and bad providers don’t. Creating an environment where providers know what their incentive is, and where employers or payers know that because they are partnering with Bardavon, they are getting access to the best providers in every community that are uniquely focused on the same goal that the employer wants, getting that employee back to work and effectively doing their job.

You used the word “grind” several times in an interview, talking about your college athletics experience where a bigger and more athletically gifted opponent knocks you down and you have to get back up and do it again. How does that personal philosophy translate into a business culture, especially in an environment where employees might not be as willing to sacrifice their lifestyle for company benefit?

I was blessed to not be exceptionally good at anything. It taught me the importance of work and that I could succeed if I would outwork others. My parents and growing up on a farm were surely a part of that, but the fact that I wasn’t blessed with any exceptional talent really was a blessing. It helped me, and that transcended from sports to business. The Midwest is part of that.

In all of the healthcare, and specifically now in every industry like this, I guess there’s always a level of negativity and a level of suspicion about whether people are doing the right thing. This business has been my choice to pursue my entire life, in large part because if you spend time with these patients, they are incredibly inspiring.

My entree into workers’ comp was working with professional athletes who were hurt. I saw all the technology and all the science that was aimed at getting a professional basketball player back to the court or professional football player back on the field. When you are able to take a piece of that and provide it to firefighters, police officers, and laborers who are doing their job very specifically to support their husband, wife, kids, families, friends, whatever … there are always bad actors and characters, but predominantly it is a remarkably inspiring client base and I’m proud of what we can do. It keeps me guided to grind every day.

The other side of that is those providers, specifically the physical and occupational therapy providers who spend so much time with their patients. An hour a day, three or four times a week, for five to six weeks. It’s a very intimate relationship. They put their hands on them and they help them regain the function they once had. They hear about their families and they hear about their personal lives. It is a really beautiful sector of healthcare that has been historically neglected and forgotten. I’m proud of the focus that we can put on it through our own grinding effort.

How will the company change over the next few years?

Cliff and Neal were always clear about having a vivid description of a desired future state. Keep that at the forefront of everything you are doing and why you are doing it. We believe that Bardavon will continue to evolve into a company that represents excellence in the way that employers treat their employees, specifically around MSK health. We will facilitate meaningful and intuitive technologies, services, and when appropriate, exceptional patient care for those associates, so that they know that when choosing an employer, they will assess whether or not that employer works with Bardavon. The providers they work with around the country will see that as a part of brand associated with quality and caring for them as people in their roles and jobs and lives.

I believe that we are on the precipice of that. I believe that as we grow and become the company that we can, that others in this space copy us and take that approach to other parts of the healthcare spectrum and continue to improve their lives as well. That’s probably a bold prediction, but I believe it.

HIStalk Interviews Joshua Pickus, JD, CEO, Net Health

Joshua “Josh” Pickus, JD is CEO of Net Health of Pittsburgh, PA.

Tell me about yourself and the company.

I am a serial CEO of technology companies. This is the second healthcare tech company that I’ve run. Net Health is a EHR and analytics company that is focused on medical specialties, such as therapy and wound care.

How do the EHR needs of skilled nursing facilities, senior living operations, and home health differ from those of hospitals?

Let me give you an example to make this real. I’ll do it in terms of physical therapy. In some respects, there are real commonalities. In all cases, you need to accurately document the care in a way that is compliant with the reimbursement codes. You need to do that whether you’re in a hospital, a skilled nursing facility, or an outpatient clinic.

But there are very important differences, and they often end up having to do with things like integrations. In a hospital context, in most of our situations, it’s critical that our systems interoperate with major hospital EHR players such as Epic, Cerner, and Meditech. Making those integrations seamless is frankly as important as the functionality that we have in our own product.

If you contrast that on the other end with, say, a outpatient clinic or facility, that’s a much less critical piece of what they do. They probably don’t have a direct interface with Epic, and that’s not that important to them. Skilled nursing facilities are somewhere in the middle. There are key integrations, principally to PointClickCare and MatrixCare, but it’s different players. Our functionality may be quite different, but the integrations to other systems are quite different among settings and are very important.

The early days of COVID forced hospitals to coordinate with post-acute facilities to free up beds, and CMS added some requirements around that coordination. Is that data sharing relationship among types of entities improving?

Yes. We are unique in that in the specialties we serve, we are really hospital-to-home. We have to think about that stuff. You are right that the pandemic brought those issues to the fore. As a result, the pace of progress has improved.

But the core issue is still simple. There isn’t a common system or even a common accepted language to go from hospital to home, to transmit core patient data seamlessly, easily, and accurately. We are focused on the FHIR standard, which is the closest thing we have right now to a standard that lets different systems at different parts in the continuum talk to each other.

A lot of our work is on improving our FHIR capabilities and making it truly seamless, so that basic information can easily pass from one setting to another in a way that the recipient and the provider of the information actually know what’s going on. You would be shocked that basic stuff — like if you’re a nursing home and you want to know something beyond the patient’s name and age, such as the existence of any behavioral health concerns —  isn’t as easy as you would think given that it is a specific, easy thing that you get every time. Working through FHIR to improve that interoperability continues to be a key focus and challenge for us.

How do you expect the hospital-at-home and remote patient monitoring concepts to play out?

I would respond differently to the two things you mentioned, in terms of the timeframe. Remote patient monitoring is here. It’s real. It’s in use. It’s quite valuable. I think it will expand and pretty dramatically. Hospital-at-home is interesting, but in its infancy and less likely, in the near to immediate term, to affect the way that care is delivered. 

We are more focused on remote patient monitoring and all types of remote care, even if the locus of care is still a hospital-based physician. There are a lot of things that can be done by that physician or caregiver without the patient in the room. That feels real to us, and we are introducing all kinds of capabilities to support that trend.

Will device connectivity and integration issues present challenges?

In the grand scheme of things, the technology is the least of the problems. If you break it down, think about the most basic form of telehealth, which is simply a audio and video call between a caregiver and a patient. That exists, it works pretty well today, and it turns out that it is really valuable. I live in Utah, and about half the time when I see my providers at the University of Utah, we do it virtually. To me, that’s here, that’s ready, that works.

Then you get into slightly more sophisticated stuff. Can a patient who has a wound that needs monitored get that captured by their iPhone and send the picture to the hospital that’s caring for them so they don’t have to make a two-hour journey? It turns out that’s available, too. You could go on and say, can you monitor a patient who is undergoing physical therapy and you want to accurately gauge their range of motion through sensors? That’s available today. too.

I don’t want to minimize the technology challenge. There is plenty of improvement, but it is much more behavioral change that is the obstacle to that than the actual technology.

What are skilled nursing facilities doing with analytics?

SNFs don’t have the budgets that hospitals do. As a result, spending on analytics isn’t anywhere near as large as it is in hospitals. But they are doing important things. 

One that is critical to both hospitals and SNFs is readmissions of patients. If a hospital sends a patient to a SNF and then the patient bounces back, that is bad for everyone concerned, especially the patient. So, one of the things that SNFs are focused on is preventing hospital readmissions. How do you do that?

It turns out that oftentimes what causes a readmission is something as basic as a patient falling, reinjuring themselves and needing a more acute level of care. If you can monitor fall risk and accurately determine which patients are at greater risk and take steps to prevent that fall from occurring, you will reduce readmissions. And if you reduce readmissions, everybody, including the patient, is a lot happier. There are some tangible things that SNFs are doing with analytics, and many of them actually relate to the hospital that sent the patient in the first place.

Are hospitals rewarded for discharging patients to facilities that perform better, and do they provide technical or financial assistance to those organizations to improve outcomes?

There are two ways in which that is occurring, and it’s real. There’s kind of a formal and informal way.

In the formal way, you will have hospital-based ACOs, or accountable care organizations, and they will have formal arrangements with downstream providers. The payments to the provider will be dependent on specific metrics, of which hospital readmission is usually at the top. That exists, but it’s not yet terribly widespread.

The more common arrangement is that many, if not most, hospitals maintain networks of skilled nursing facilities and are deciding where to send the patient. Increasingly, they are focused on the patient experience. There are very different levels of sophistication that this is being done with.

Well-managed networks will pay attention to five or 10 metrics, ranging from readmission to customer satisfaction, about the patients who they send downstream. That will affect where the next placement goes. That incents the SNFs in a very real way to achieve against those metrics, because it will determine the patient flow. That became less powerful in some respects during the pandemic because there was such a bed shortage that it didn’t matter. But as we exit that period, that’s becoming relevant again. It does impact their top line, in terms of their census, based on whether hospitals are sending them patients.

How did your Tissue Analytics product earn FDA’s Breakthrough Device status and how are customers using it?

This is genuinely cool, and it is novel. In fact, it was novel to us, because it’s called Breakthrough Device status and we don’t make devices, we make software.

It turns out that software that makes predictions that affect outcomes in care is regulated by the FDA as a device. Breakthrough Device status means is that you have built something that is so novel and potentially so beneficial to patients that FDA is going to put you in this Breakthrough Device category. They will expedite the review that you need to get an approval to have your product sold and used for particular applications. It was a journey for us, as a software company, to enter the FDA regulatory scheme.

We are doing things like predicting the velocity at which a wound will heal, predicting amputation risk, and ultimately predicting which kind of treatments are most likely to lead to an expeditious and effective piece of care. We have demonstrated that we now have enough data that we can accurately predict that “this patient needs this many visits of this duration to achieve that result” or “this patient is at materially higher risk of amputation if action isn’t taken immediately.” It’s making a real-world difference out there. We probably have 50 or 70 customers using these modules, so it is becoming an accepted part of wound care practice.

Will the experience that the company gained from working with predictive AI and the FDA influence future product development?

Very much so. We view analytics as a key piece of where EHRs are going. If you think about it, EHRs have traditionally been systems of documentation. They exist so that you can document the care given. That’s a baseline requirement, but it’s not really where EHRs are going. EHRs are becoming systems of insight and systems of engagement, in addition to systems of documentation.

By systems of insight, I mean that if you are the system through which the clinical workflow is happening, you have a unique opportunity to collect data about what works and what doesn’t. This is the piece that people miss. You also have a unique opportunity to put insights back in the workflow to alert a clinician at the precise moment, which increases the quality of care that they can deliver.

The analytics piece for us and the predictive piece for us is very much about the next chapter in what an EHR is. It’s really about harvesting the data to yield insights that you can feed back to clinicians that enable them to deliver better and more cost effective care. It’s at the very heart of where we’re evolving our systems.

You’ve said previously that a lot of EHR frustration is due to entry of that isn’t used to change outcomes and doesn’t directly support the clinician who is expected to enter it. How will that evolve?

General purpose hospital EHRs like Epic and Cerner will also include analytics and predictive analytics as key parts of what they are doing. Those are sophisticated companies. They understand that this is the next chapter for EHRs, and they will participate in that. We view ourselves as additive to what they do, because the workflows and the data that we capture are unique to the specialties we serve. To be able to deliver accurate predictions and useful clinical insights, you need that unique workflow and unique data.

We think that what we are doing and what they are doing are complementary. We work in many hospitals with both Epic and Cerner. Virtually every installation of our Tissue Analytics product is with a system that runs Epic or Cerner, so it is important for us to be complimentary and to interoperate with them.

What changes do you expect in the company and the industry over the next few years?

If I were going to give you two words, it would be more interoperability and more analytics, especially predictive analytics. Both of those things will become so embedded in what we do that you can’t really separate that piece from us. The importance of connecting with other systems and the importance of using the data that you have to deliver insights is really the future that we see as Net Health continues to evolve.

HIStalk Interviews George Dealy, VP of Healthcare Solutions, Dimensional Insight

George Dealy, MS is VP of healthcare solutions for Dimensional Insight of Burlington, MA.

Tell me about yourself and the company.

We’ve been building analytics technology for the last 30 years. My group uses the Dimensional Insight technology, the Diver analytical platform, to create healthcare-specific analytical applications that solve various problems within the healthcare system, primarily focused on the provider environment, but we also have payer and manufacturer customers.

I have been with Dimensional Insight for 15 years and in the healthcare IT space for 27 years. Before that, I was in the data management database area, working for companies such as Sybase in the early days of RDBMS technology. I was there for 10 years before I moved into healthcare-specific technology.

Do customers want a platform that allows them to develop their own analytics or do they prefer pre-built solutions that have been proven to work elsewhere?

We’ve seen a transition, over the course of the last five or six years, from folks wanting to build their own solutions to their own problems to being open to pre-packaged solutions like the ones that my group builds. Then, extending them for their own purposes.

But even beyond that, we’ve seen some of our larger health system customers essentially almost outsource their analytics process to us. They consume the data and they decide what problems we’re going to focus on solving, but they look to us to do the actual development work. A consequence of that is that they are able to put more focus on actually using the data versus building the systems.

Do they just give you a description of their problem or do they already suspect its underlying cause?

It depends. We have a family of eight healthcare solutions. We will typically start a conversation with a customer for a particular problem. I’ll use the example of a surgical service line where there’s lots of information. There are challenges around things like throughput and patient flow. They’re turning ORs around. We have a solution that provides common KPIs for that particular class of problem. They are able to extend that to more specific manifestations of those problems. We typically start with a pretty well-defined starting point for a particular problem. If their problem is something other than what we have a pre-packaged solution for, we still have a starting point in terms of the way that we go about developing applications.

We’ve created some technology that sits on top of our analytics platform and simplifies the process of defining and then calculating KPIs. One of the things that that tool has allowed us to do is to get the folks who understand the data and the problem they are trying to solve more directly involved in the process of defining and creating these analytical applications. That has also put our customers in a position to create their own applications in a similar style to the ones that we create. Among the organizations that have the wherewithal to do that, typically the larger health systems, we’ve seen a lot of innovation around things that we hadn’t thought about for one reason or another. They are solving the issues that are important to them.

Does the challenge remain that executives commission reports that frontline managers don’t use?

Two observations. One is that it starts at the top. You get good results if a CEO, COO, or C-suite executive who has operating responsibility is watching those numbers and holding the folks who report to them accountable. They have to then do the same thing right on down the line. I have a few customers where that’s the case and their execution is very good, largely as a result of having the information, but also selecting the right information to focus on.

The other thing is that my sense is that being data driven is something of a generational change or evolution. Folks who grew up with electronic media, understand information, and aren’t afraid of it are more open to incorporating it into their thought process. That’s not to say that folks in my generation aren’t open to it, but I think there’s more consistency around the younger side of the workforce because it’s what they’ve grown up with.

Do people have eye-opening moments when analytics shows them something they didn’t suspect?

All the time. There’s tremendous confirmation bias all over the place. You hear the story told frequently about surgeons and physicians who have this intuitive sense that their particular approach to a procedure or a diagnosis is the only way that you would do it and that it’s as effective as it can be. Then they start looking at the data from their peers in similar situations and realize that they didn’t know some things. Similar lessons apply on the operational side pretty much wherever there’s data. 

We have that in our personal lives, too. We think that something is a certain way, but when when we start quantifying it, we realize that it’s very different. You’re used to going a certain route and your GPS system tells you to go a different way that you never even thought about, and it turns out to be shorter and faster.

What are examples of customers using analytics to solve a vexing problem?

I would break this down into a couple of categories. Operational efficiency is a big area where it’s really not clear what is going on in complex processes. You look at patient flow through a hospital, where a patient comes in through the ED or maybe is going for elective surgery, and there are all these way stations along the way where there are potential bottlenecks that get in the way of freeing up beds for patients, getting patients discharged on time so that you can bring more patients into the hospital. Hospitals make much of their revenue on fixed-fee DRG hospitalization, so moving patients through the system as efficiently as possible is key.

Our customers use KPIs that break those work processes and flows down to where they can identify where the issues are. For example, moving certain bottlenecks out of the way to discharge patients from the hospital more quickly, or at least by a particular threshold that they’ve set. That would be one example of something that improves patient flow. Further back in the process, the emergency department, where a variety of bottlenecks can emerge, largely around the ancillary services, getting appropriate turnaround times on things like imaging and lab procedures.

Those are some operational areas where our clients have been able to improve using information to identify the problem, solve it, verify that there was an impact, and then monitor it to make sure that it doesn’t regress back to where they started, which can often happen if you don’t have ongoing visibility into the information.

On the clinical side, I’ll give you one example of a academic medical center customer that we began working with fairly recently who has come up with an algorithm for assessing mental health issues, specifically suicide risk. We work with them to integrate that algorithm into information that was compiled from EHRs. The patient clinical data is combined with the algorithm to come up with a risk assessment for suicide that can be used directly by providers when they are interacting with patients or prior to interacting with them in a formal healthcare setting. Or, to identify cohorts in a population that are at high risk for suicide.

Do customers often learn from analytics how to identify and replicate their own best practices?

That’s the whole premise and the opportunity for some of the advanced techniques around analytics. We have tremendous amounts of data, starting with the Meaningful Use era, where EHRs with clinical capabilities came into the healthcare environment in a way that they weren’t there before. You have 10 years of data that is getting better as time goes on. There’s still a data quality issue and data standardization issue, but as those issues get dealt with and interoperability becomes more standardized, you can compile a more complete picture of a profile of patients and populations. 

Then you are in a position to assemble this big base of information and use it to compare to outcomes over time and determine what care processes, what approaches have been most effective for improving outcomes or attaining a particular target level of outcome and eliminating some of the adverse events and consequences that can come when things fall through the cracks where processes aren’t followed. Or maybe there are suboptimal processes to begin with.

How have health system expectations for return on investment changed with the pandemic?

The big issue during and coming out of the pandemic is around staffing. The physician staffing shortage was there prior to COVID, but nursing is largely a consequence of COVID. Efficiency and productivity become that much more important because you’re dealing with limited staff resources. We have a lot of prospective clients looking at solutions to that type of problem. How do you objectively measure and improve efficiency and productivity given limited personnel resources?

I just realized that I haven’t heard the term “big data” used lately. Do health systems still need external data or they they have enough information of their own to make decisions?

That’s interesting, I don’t think I’ve heard the term “big data” in a while either. I think that may have come and gone. Maybe it’s just taken for granted at this point, with the likes of what we see with Google or Facebook. The amount of information that you can deal with is almost infinite from a practical standpoint. The capability is there, but the issue has shifted to, what big data? What are you going to use it for?

I was reading a research paper that came out of the MIT Healthcare Learning Lab, where they are they are experimenting with what they call multi-modal approaches to machine learning in healthcare. They are looking at not just the traditional, highly structured, tech-based information that comes out of EHR, but combining that with voice recordings, video, waveforms, and time series imaging, teasing value out of that to predict certain well-defined outcomes. This particular paper was looking at predicting length of stay in hospital, 48-hour mortality, and a few other things. They found that they could get a boost — it wasn’t a huge boost, but it was still a meaningful one – by employing some of these other modes on top of what we think of as the traditional information that gets collected and structured within an EHR. That’s huge data, maybe the next step up from big data.

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

Continuing to get the data house in order. There are tremendous opportunities and possibilities around these advanced analytic techniques, but it requires good data. We are focused on identifying what that data is and curating it to the extent that it’s meaningful within the organization. In other words, you don’t have five different ways of measuring exactly the same thing. There may be some meaningful variation, but reducing that duplication and quantitatively defining outcomes. Once you have that, you open up more opportunities for using these advanced techniques to become more efficient and productive and to improve outcomes.

Things like the standardization of vocabularies on the clinical side. SNOMED, RxNorm and LOINC have been around for a while, but they are gradually making their way into practice. As you get more standardized data, it’s higher quality in terms of what you can do with it. The HL7 FHIR standards are going to help in terms of being able to compile the standardized information around a patient or a population of patients so that you have more and more high-quality data to work with.

A lot of it is somewhat routine blocking and tackling, but until that happens, the potential for the more advanced techniques is going to be limited. But healthcare in general is very much looking forward to what advanced analytics can do. As you look around other industries, it’s pretty clear that it has the potential to make a huge difference, but you need to have the data in place and you need to understand what it is you’re trying to do with it.

HIStalk Interviews Eric Meier, CEO, Owl

Eric Meier, MBA is president and CEO of Owl of Portland, OR.

Tell me about yourself and the company.

I’ve been in the healthcare field for the majority of my career, both on the software side as well as the technology and medical device area. This area is probably lagging other specialties in technology, software, and analytics. This is the realm of behavioral health, which is the largest category spend in healthcare — I think it’s over a quarter trillion dollars spent on services. You can look at the impact from our productivity in our society. I don’t know the current prevalence of behavioral health conditions, but I think that an excess of 16% of the American population has suffered from behavioral health issues. 

We came into the market realizing that unlike other specialties, there was really not a good way to determine and understand if care is working correctly. Behavioral health has been a people-based therapy and involves medication as well as psychotherapy. The ability to assess whether treatment is working has been lagging. Somewhere between 11 and 13% of clinicians are practicing measurement-based care, but it has been shown clinically to be extremely effective way to deliver effective and efficient care.

We were founded at University of Washington, looking to deliver an approach that would allow clinicians to understand or address the fundamental question — is care working, and to what extent? We’ve built upon that over the last five or six years.

What’s encouraging about it is that this methodology of measurement-based care clearly works. The platform was designed by clinicians for clinicians. When you take that type of approach, you can get an understanding of how treatment is being delivered and how effective it is at every step of the journey. 

We are seeing engagement rates well in excess of 90%, which means it is integrated into care effectively and is able to understand what’s the patient’s status at intake from a screening standpoint, but also being able to work alongside the treatment throughout the entire course of treatment. When it’s time to discharge, step down care, or have patients transition away from receiving services, understand the effectiveness from admit to discharge, and then if needed, to see if in fact there is a relapse, being able to detect that early on so care can be administered correctly if needed down the road.

What kind of measurements are used, and how many of them reflect the patient’s perception?

Patient-reported information is a true proxy of the patient’s status, not only for screening, but throughout the course of treatment. It minimizes clinician burden and it has been shown to remove quite a bit of subjectivity or bias. If you look at the early days of capturing assessments for clinical care, a lot of these were physician-reported scales. Over time, what has been increasingly accepted and recognized is that the patient can provide a far better status of their own condition. That also avoids the pitfall of many technologies in burdening clinicians with additional work.

We adopted the approach at the outset of capturing the patient’s status using patient-reported outcomes measurements or what is referred to as PROMs, in addition to looking at social determinants of health information, which in many ways can be key indicators of the patient’s status. Often in many cases, even a leading indicator — one needs to address issues like food insecurity, homelessness, et cetera. We provide this information to clinicians to help understand the condition at the time of screening or intake, then risk stratify populations, then being able to monitor or track treatment effectiveness over time.

Will those measurements became a standard for payers, similar to prior authorization?

I would look at the issue and say, why to date has it not been broadly accepted? I think it’s because of a number of previous solutions were fairly burdensome, relying upon either the clinicians to administer these tools or not fitting into the clinical workflow. We’ve taken a deliberate approach to make it fit into the existing behavioral health practice, whether it’s ambulatory, partial hospitalization or intensive outpatient, inpatient, or residential. You have to look at the clinical workflow and make sure that whatever you’re doing to capture critical information, like what we capture in Owl, fits in the existing environment.

On top of that, I’m pleased to say that there are existing CPT codes to support the capture of information that feeds into measurement- based care. We have customers being reimbursed for this. But you could also look at this information to be critical in the utilization management process, if you want to know that effective care has been delivered or if you need to extend treatment. We have customers using this information to help provide greater transparency around the type of services that have been delivered and how effective they are.

Behavioral health providers have been reluctant to use some technologies because of privacy concerns. Is that an issue?

We really haven’t seen that be an issue. The major questions around adoption are, how does this fit into my existing workflow, or how does this help me institute change management in a way that’s not overly burdensome and can actually make the capture of information easier? 

Around privacy concerns, we have developed a HIPAA-compliant system that is observant and supports conditions around privacy. There are additional requirements as it relates to substance use, but at least from our vantage point, we have not seen that be an issue around adoption of technology. It’s more about just making sure that it fits within the existing treatment model and doesn’t overly burden the clinicians, but actually give them greater information around the kind of care they’re delivering and making sure that using a platform to help improve the overall effectiveness and efficiency of care.

Who makes the decision to implement the concept as well as the technology?

If you look at our customer census — Ascension Health, Oregon Health and Science University, Texas Children’s, Inova Health System, and Carilion Clinic — it starts with leadership that is thinking strategically on how to deal with the basic questions of, how do I deliver the most effective and efficient care? How do I deal with access issues and try to address wait lists that may be occurring? How do I better understand, from a population health standpoint, the type of care that is being delivered within my ecosystem and also support alternate payment schemes, such as value-based care?

All of that hinges upon the understanding of the type of care that’s being delivered, which has been well accepted through the capture of clinical outcomes. With any new technology, getting leadership buy-in up front is crucial to embark upon measurement-based care, but also make sure it’s being utilized by the team on an ongoing basis.

We have been fortunate that our customers tend to think strategically on addressing the fundamental question of how effective is the care, how good a job am I doing? Then making sure that as we look at this from an implementation standpoint, it needs to fit the existing ecosystem, which typically consists of integration with their EHR, whether it’s Epic, Cerner, Athenahealth, or behavioral health EHR such as Netsmart, Streamline, and others. Then secondarily, make sure that information can be used on demand by the clinicians as part of an encounter, but also used by the leadership to assess the effectiveness and efficiency of care across their different clinical programs. 

When you think about the ability to benchmark, let’s take for example eating disorder service lines that may be spread across a health system in different locations. What you would like to understand is, how good a job am I doing? Am I seeing kind of best practices in one location that I can now, based upon the outcomes data that the Owl is generating, replicate and standardize on? 

The other point that needs to be understood is that people delivering behavioral health have probably one of the toughest jobs in healthcare. It is a really challenging job. Well accepted is its ability to not only provide effective care, but get more out of existing resources. For example, we’ve seen about a 56% reduction in time to remission from those folks that implemented the Owl versus those that have not.

Secondarily, given some of the resource constraints that have unfortunately become a consistent problem across the United States, we’re seeing about a 30% improvement in staff efficiency. You take an organization that may have 20 to 25% attrition, there’s a need to backfill those positions, but also make sure the consistency of care is happening across a health system, whether it’s in one geography or multiple. The beauty of the Owl is it provides a systematic way to deliver evidence-based care, and when you think of faster time to remission, I can treat more clients with existing resources.

How are measurement-based outcomes being used in telehealth?

We are an enabler to that. We were designed from inception to support telehealth, long before the pandemic occurred. Virtually 100% of our customers, going back to probably the second quarter of 2020, by necessity pivoted to a virtual healthcare model and, there was no interruption of the use. In fact, one of the things we’re proud of is that our platform has been used to assess the overall effectiveness and efficiency of care in both the on-premise as well as virtual setting. We’re seeing a consistent response. The upside for the patients is you have the ability to receive treatment services in probably a more relaxed setting. You avoid having the transportation and having to go to your appointment. Our platform has been used to give confidence to the providers that the quality of care is not compromised.

When you think about what is happening right now with the fact that there’s been a big focus on access to care and our platform is being used to support improved access to a faster time to remission or whatever your treatment target is, as well as the ability to be able to treat more in patients with existing resources, we’ve been well accepted in providing those values. I would say as you look forward, we think there’s going to be increasing focus on quality. As the access issue begins to abate, we are seeing health plans is saying, that’s great, let’s make sure that the quality of care is not compromised. The payers or the health plans are demanding more data, in the form of clinical outcomes, to document and validate that the treatment services have been administered correctly.

That’s the work we do. Think of us as not only supporting the providers and being able to deliver evidence-based care through the Owl of the measurement-based care platform in a seamless way, but secondarily provide the health plans to better understand the performance of their networks. There’s no better way to do that than to have well-documented, patient-reported clinical outcomes and social determinants of health information to make sure that the best care has been provided at the right level to the patients.

What changes do you expect to see over the next few years with your customers and the company?

In the early days of the company, it was around providing or enabling providers to capture clinical outcomes in a straightforward way. We’ve been able to provide information capture to our customers.

If you look at the evolution of measurement-based care, the next piece of the puzzle is providing detailed reporting and analytics to support internal needs around as a health system. How good a job am I doing relative to where I want to be from a performance standpoint? I think of this as a population health support.

The next area has been in supporting clinical decision support. Not only can I use measurement-based care to determine those clients or patients that may be likely to self-harm or harm others, so looking at suicidal ideation, our platform is designed to provide a safety plan to not only notify the clinicians and staff that immediate attention is warranted, but also say, what do you do? We’re building upon that now to look at different conditions such as depression, anxiety, substance use, et cetera, to provide supportive clinical decision-making so you are administering the right care algorithm.

The fourth area I would speak to is providing greater alignment between providers and plans. Providing visibility, which to date has been opaque, around the overall care that has been delivered by both the behavioral health specialty and primary care. Having an understanding of how a health plan’s network is performing, and once you baseline that information, then it provides the opportunity to be aligned around moving towards alternative payment schemes, such as value-based care.

As we look forward, we see not only continued and growing acceptance of measurement-based care by providers, but health plans using this information to understand the quality of care that has been delivered and making sure there’s alignment around payment schemes and addressing total cost of care.

From a business strategy standpoint, where we are focused is having a balanced portfolio of customers. Not only serving health systems, large community mental health clinics, and health systems supporting both behavioral health specialty and those that move into collaborative care or integrative care model, but also making sure the health plans are able to understand the type of care that’s been delivered. Not only behavioral health, but also recognizing that these behavioral health conditions can adversely impact medical care. This whole concept of whole person care is going to be critical and recognizing you need to address the behavioral health component of it.

We benefited from taking a clean slate five to seven years ago and the ability to develop a measurement-based care platform by clinicians, for clinicians. The area we focused on was number one, making sure we integrate in the clinical workflow in a seamless capacity. This is across different clinical approaches to delivering behavioral health services, everything from ambulatory to partial hospitalization, intensive outpatient, inpatient, as well as residential. We’ve extended that to support when behavioral health is being delivered in a primary care setting as well. Secondarily, once you fit the clinical workflows, to make sure you’ve got a broad enough amount of content that support all the different subspecialties, whether it’s eating disorder, substance use, depression, anxiety, adolescent, or late-life care. 

The upside of this is we’ve got a high engagement level, upwards of 90%. You need those kinds of numbers to fully utilize measurement-based care and capture the benefits of accelerating time to remission and improving effectiveness of care as well as efficiency. Once you accomplish that, you start to address one of the primary issues today, which is access to care. In other words, how do you make sure clients are receiving care in a timely capacity? As I mentioned earlier, we’re seeing compelling and supportive statistics with faster time to remission of 56%, as well as being able to get more out of existing resources.

With that in mind, with this information, then it becomes meaningful not only for providers, but also obviously those that are doing accreditation work, such as the Joint Commission or CARF, as part of their audit process. Lastly is making sure that the health plan has a better sense of the type of care that’s being delivered by their network.

We have been fortunate to have supportive strategic investors in the form of the Ascension Health Network, First Trust, Cardinal Partners, Blue Venture Fund, and the Entrepreneurs Fund.

HIStalk Interviews Ben Albert, CEO, Upfront Healthcare

Ben Albert, MBA is co-founder and CEO of Upfront Healthcare of Chicago, IL.

Tell me about yourself and the company.

I have been in healthcare for my whole career. Prior to starting Upfront, I founded a company called Care Team Connect, which was a care management platform for population health that was acquired by The Advisory Board. We did a lot of care management work through a digital platform that enabled care managers to support the high-risk patients that they were serving and supporting in a shared risk agreement.

That experience it led me to found Upfront, because every patient, not only those who are high-risk in some population health agreement, deserves to be navigated to the care that they need, and technology is required in order to scale that type of navigation for every single patient across a health system. That is the foundation of Upfront Healthcare, to help every patient get the care they need.

How do you differentiate the patient engagement and digital front door technology market?

It’s a confusing market, for sure. The digital front door is mostly tied to patient acquisition. Where Upfront focuses is on how to retain every single patient that you serve. If the digital front door is going to bring in a bunch of new patients, how do you use personalized engagement and access to optimize the experience for that patient so they stay with the system for the long term after the digital front door is activated and you engage that patient initially?

Health systems are starting to understand how to get patients into the system. Do they also study why patients leave the system?

They definitely study why patients leave the system. They look at referral patterns and if patients are leaking out. If they are being used as a retail service and the front door generates only retail visits, how can they convert that patient into an empaneled patient on the primary care side or the system of choice for that patient for the long term?

They definitely look at that conversion and understand how to keep that patient and retain them. Especially in light of all of the specialized services that are coming to market, Amazon and Oak Street Health for example, that are focused on particular types of patients, to help attract those patients to their services. Our clients, the health systems, need to focus on how to differentiate and keep their existing patients.

How do health systems engage with patients whose encounter was one-off, such as in an urgent care center or telehealth visit, and determine how much of a relationship those patients want?

They need to engage those patients through a more personalized experience to help understand the needs of those patients and then guide them to that service proactively. Patients are often left to figure that out on their own. They might get a simple text message thanking them for their visit or preparing them for a visit, but they aren’t really aware of options within the system and how to best use the system to meet their own needs.

We often talk about patients as the most underutilized resource in healthcare. How does the health system look at that initial encounter or initial event as a way to help educate the patient about all the services that are available to them in a personalized way, so that only those services that are going to be the most impactful for that patient are put in front of them?

How is that different from retailers, who are happy to sell you whatever you want to buy and hope you keep buying, when what patients want isn’t always what clinicians think they need?

The patient will make the right choice if they are given the education and the appropriate information to enable them to make that choice. Often the clinician might be communicating what the patient needs, but the patient doesn’t understand it at the time that communication is provided. It’s not as personalized in some ways as it could be.

You can give patient the alternatives in how to get that care. Let’s say it’s a flu shot for example, something very simple. You give them the alternatives of, you don’t have to go to your primary care physician because we have these different options for care for you, including our urgent care, where you can get this flu shot. We are going to help guide you and let you pick what service is most convenient for you to get that care that you need. It flips it around a little bit to give that patient choice to meet the needs that they have by availing them of the information to optimize their own care.

Is there any comparison to dental practices that message their patients effectively, albeit with list of services that is much shorter and predictable than that of a health system?

It will be as simple as that. It’s not the complexity of the system, it’s the communication of what pieces of the system meet the needs of the patient. 

There is a way — we call it care traffic control — to understand all the services that a health system can provide to a patient, and then to personalize that service and the access to those services so that the patient will know exactly where they’re supposed to go and when they’re supposed to go there. They will get that care that they need from the system and it won’t feel so complicated. It won’t feel like there are so many choices because it has been tailored for them and guides them directly to where they need to go.

So yes, it can feel like the dentist. Does it today? No, because it’s a lot of fragmented communication coming through different channels that confuses a patient as opposed to one omnichannel communication that will ultimately all be on the same page to enable that patient to get where they need to go.

How will you apply the consumer science capabilities of PatientBond, which Upfront acquired in August 2022?

We are excited about the acquisition of PatientBond. Psychographics, in combination with the behavioral analytics that we already do at Upfront, will help us understand how to best engage a person. Psychographics are a consumer capability that helps create these personas of individuals, so that we know exactly what communication pathway to take to engage that person so that we can ultimately understand how to best communicate with them.

You use the right imagery, you use the right language, you use the right time of day and super tailor and personalize the experience for that individual. You tie that in with the behavioral knowledge that the Upfront platform has and that really understands that when they go for care, where they need to go. You optimally tie those things together to have a communication pathway, then access that pathway for a patient that is unique to them and scalable. They are getting to that care 40% more than they were before because of that communication pathway.

If value-based care ever becomes significant and maintenance of health becomes more financially important to providers, will the same messaging platform support it?

Yes. From our point of view, whether it’s value-based care or not, every patient should be getting these necessary preventative services. How it gets paid for on the back end, we certainly understand the value of that. But ultimately if you take the patient-first approach, everybody should be getting that annual wellness visit who needs it and everybody should have those care gaps closed who need them, not only if they’re in some value-based care arrangement.

How do you help every single patient, regardless of what the economics are behind their care, get to the most optimal care for them? It’s informed by what type of care they need to receive and what type of model of care they’re in to make it super efficient for the health system while still enabling every patient to get the same level of care across the system. In a value-based care context it’s incredibly important, but it’s equally important in a fee-for-service context where these patients still need that same care.

How do health systems change their philosophy about consumerism and then choose systems to support it?

They all want to be more consumer centric and they’re on this journey to be so. They have built all of these services, retail-type services like urgent care, virtual care, on-demand care services, asynchronous care, and in-person services like traditional office visits. They have built all of these services to be more consumer centric, tried to increase access points, tried to make themselves more convenient.

Ultimately, though, they have not optimized that for the patient. What they are doing now in that next wave is saying, we have all these services and we can compete for access, convenience, and efficiency for the patient. How do we tie it all together and enable the patient to understand which one of those services they should be utilizing within our system to ultimately get the best experience for them and get in for care when they need it?

We see a big effort in tying that all together to make it feel seamless for the patient, even though we know that under the hood, it’s not as seamless as it probably should be in the long term from a health system point of view. You can enable the patient in a way that feels seamless and guides them across those services. That’s how they are digitally transforming right now. The first step is how to enable that consumer even if you can’t fix everything across the system on the back end right now.

Does consolidation into larger health systems change the scale and speed in moving to a more patient-focused direction and the use of technology to support it?

In theory it’s helpful, but ultimately you are now on multiple EMRs. You have to reconcile all of that data and all of those services across the system. Unless you have something that can sit beside the EMR, sit outside of that ecosystem and look across multiple EMRs to understand what services are available and guide patients, it doesn’t actually advance the cause. It can slow it down because of the focus is so heavily on the EMR itself and not on how to activate your patients and help all those patients navigate through the integration of a couple of systems coming together, which is incredibly complex for patients to navigate, but also for the system to execute on as well.

How do you see the consumerism aspect of playing out over the next few years and how will the company change in response to it?

To us, healthcare needs better personalization for every single patient. The more we can delve into truly understanding exactly what service the patient needs and enabling them proactively to get that service, the more efficient we will be at a macro level. For us, it’s continuing to enable patients through personalization, through psychographics, through behavioral data, through the right type of communication and omnichannel communication that is integrated across the system so that access and appointment booking is frictionless and easy to get to. 

I would love to say that it’s a one-year journey to be able to tie all of that together, but those of us who have been in this industry for a long time recognize the complexity of it. We will just stay with it and keep doing more of it over the next few years, and you’ll look back at the body of work and say, wow, we’ve made a big impact. More patients are getting the care they need. They are getting a personalized experience that feels much more consumer centric, and they are actually healthier as a result.

HIStalk Interviews Douglas Fridsma, MD, CMIO, Datavant

Douglas Fridsma, MD, PhD is chief medical informatics officer of Datavant of San Francisco, CA.

Tell me about yourself and the company.

I’m the chief medical informatics officer at Datavant. Before that, I was president and CEO of the American Medical Informatics Association. Before that, I was the chief science officer at the Office of the National Coordinator for Health IT during the Meaningful Use era, as we were trying to get electronic health record adoption.

A lot of the work I did at ONC was to set up the basic infrastructure for collecting data. The goal, for many of us who were working on these projects, was to make sure that once we collected the data, we would get rid of the lazy data. That is data that would  get collected and then just sit there and not be used for population health, a learning healthcare system, or those sorts of things. That’s my history and where I come from — let’s figure out ways to make data useful for patient care and for healthcare delivery.

Describe how tokenization is performed and how the information that it enables is being used in healthcare.

A lot of data out there is fragmented. If you were to try to get your medical record, you’ve got bits of your information that might be in a claims record, some of it might be in a specialty pharmacy, and some of it might be with your primary care doctor or within a hospital in which you were seen in the emergency room. The problem is that when data is distributed like that, it’s hard to bring it all together into a longitudinal view of that particular patient’s experience in the healthcare system.

If you want to link a record from one hospital to another hospital, you have to have some kind of identifiable information. But if you are using the data for research purposes, HIPAA doesn’t allow us to release that kind of information without lots and lots of safeguards, IRB approvals, and things like that.

It is possible to strip out all of the identifiable information from the medical record — eliminating names, genders, changing birth dates from a month and date to just a year, removing addresses, maybe abstracting ZIP codes to a higher level. Datavant strips out that information and replaces it with an irreversible hash that we call a token. It’s like baking a cake — you cannot go back and get back to the original ingredients. This hash is derived from a lot of that personally identifiable information, but that hash has nothing that would point that back to the original person.

Datavant allows people to de-identify their data within each of their organizations. Then we have the ability to link that data back together without ever revealing a person’s name, Social Security number, or phone number. Using these tokens allows data to  move in ways that protect patient privacy and that reduce the risk of re-identification.

How reliably can the process generate a token that correctly matches the same patient across multiple data sets?

We did a lot of work when I was at ONC on trying to make sure that we could optimize patient match. Patient match is determined by three things — the algorithm that you use; the kind of data that you use, whether you’re doing it based on a phone number or a name or something like that; and the quality of the data. Probably the biggest impact is making sure that you have high-quality data that can then go through this process to generate the tokens. We work with organizations to make sure that their addresses, for example, conform to the US Postal Service standards.

With high-quality data and the algorithms that we use to generate these tokens, our metrics can be very high. It can be almost comparable to what you would get if you had a Social Security number, the name, or all of the identifiable information. It’s quite comparable as long as you’ve gone through the process of making sure that you’ve cleaned up the data and made sure that it’s accurate and an accurate reflection of the patient’s record.

Does that raise the same challenges as in interoperability, where matching data from multiple systems then brings up the new issue of semantic interoperability, where systems represent the same data concepts differently?

You raise a really important point. Datavant can link two records together and do it in a reliable way while protecting a patient’s privacy. But suppose you have one record that has all of the diagnoses in an ICD-10 code and another one that has all the diagnoses in a SNOMED code. You’ve linked the records together and you know that it’s the same patient, but now you have semantic incompatibility between a record that was collected in ICD-10 code and another one that was collected in a SNOMED code.

That’s not part of the problem that Datavant solves. We do find, though, that in the work that the NIH has done with the N3C — the National COVID Cohort Collaborative – before they run data from everybody who is contributing data through the tokenization engine, they normalize the data to an information model that consistently represents diagnoses and consistently represents things like vaccination status or other things like that. Often you can normalize the data and make it semantically consistent at each one of those sites, and then when you combine them, that data flows together much more easily.

There are ways to do it after the fact, after you’ve done the linkages, because now you might have two records that are inconsistent. The National Library of Medicine and others have ways that you can transform, say, one code into a different code to make that happen. The issue that you raise around semantic interoperability is a critical one, but it isn’t one that is solved by the process of tokenization.

Life sciences, public health and particularly COVID research, and real-world evidence would seem to be good use cases. What opportunities and users do you see for tokenization?

Let me break that down into a couple of use cases that you mentioned and give you some examples of that.

One example that you mentioned was around COVID. We as a country were trying to understand COVID and who got vaccinated, and if they were vaccinated, what their outcome was compared to people who were not vaccinated. The challenge that we had is that people had their vaccinations done at the public health agencies, their primary care provider, or CVS and Walgreens. Their hospitalization or their care might be in an outpatient clinic, the emergency room, or in a hospital setting. The problem was this fragmentation issue. The only way to understand who got vaccinated, who got infected, and who got long COVID was to link together all these different data sources. It’s a tremendously complicated thing to do, particularly because you have to have identifiable information to be able to link, say, your pharmacy record with your emergency room record.

We worked with the NIH to create tokens across this ecosystem from pharmacy, public health, and most of the major medical research institutions in the country that were part of a research program at NIH. That allowed us to pull together all the data and then create data sets that basically said, here are the folks who got vaccinated. Here are the folks who got hospitalized. Here are the people who had long-term complications related to that. That has provided a lot of rich research for the folks at the NIH who are doing that.

We see other use cases in life sciences. When pharmaceutical companies want to do a clinical trial, they get consent to collect information as part of participation in a clinical study. They have identifiable information that they use for that study. But it’s important for drug safety to be able to monitor patients after they have left a clinical study to see if they have long-term follow-up or other things that may happen as part of their participation. That can be tremendously expensive. Those are called Phase 4 clinical studies.

We have found that a lot of life sciences companies are getting permission to tokenize the information of those patients and their record. Then they can find that patient at a population level — not at an individual level, but at a population level — to identify cohorts of patients that might, say, have an increase in their cancer risk. O they may find that their five-year follow-up was fine, but their 10-year follow-up might be more challenging. That has been tremendously valuable within real-world evidence and using that for clinical studies in the life sciences. By creating those tokens as part of that process, they are able to do a lot more of the Phase 4 studies, which are expensive and they take a long time, but to do those efficiently by using this real-world data and being able to collect it directly.

As this becomes increasingly relevant, we are finding that a lot of hospitals and providers are starting to see de-identified data as not just a nice-to-have, but part of a strategic approach to how they use data. For example, within a large-scale academic medical center, there are hospitals that will de-identify and tokenize these very large data sets, and they’ll have them within their institution. They provide the ability to link that data together and reduce the risk of breaches, reduce the risk of other problems, because the data has already been de-identified and can then be used for research purposes.

Other hospitals are taking a look and using de-identification to enhance the data that they already have. They might create tokens within their hospital, but use that as a way of drawing in other data, matching it into their population, and being able to do a richer analysis at a population health level because they have augmented the data with mortality data or with social determinants of health data that allows them to get a better picture of their population. Again, not to the individual patient level, but at that population level.

Many of the providers are using this data to participate in some of these clinical studies, to be able to take their data, de-identify it, and then make it accessible to life science companies and to people who are doing research in a way that is respectful of the patient’s privacy and that prevents that lazy data. They are able to have the data that has been collected as part of their provision of care and make it be useful for other purposes that advance our understanding of how to deliver better health and healthcare.

Could tokenization be used by an EHR or other system to de-link a patient’s identity from their detailed information so that if a hacker exfiltrated their entire database, they still couldn’t connect a patient’s identity to their data?

This whole notion of being able to take two data sets potentially that have been tokenized and not be able to link them together is a fundamental part of the Datavant technology. We have probably 100 billion records and 300 million covered lives that have been tokenized using the Datavant technology. Should someone inadvertently get a copy of, say, one hospital’s tokenized data and the records from another hospital’s tokenized data, our system creates different tokens for each of those sites so that it’s impossible, even if someone were to get that information, to be able to link it together and potentially re-identify a particular patient.

If you had a list of everybody’s name, and you tokenize that and then use that to link to other data sources, as soon as you got a link, you’d say, “I know the name of this person.” We don’t allow those kinds of linkages to occur except under strict review. We also do other reviews to make sure that, even after you’ve linked the data, it is no longer re-identifiable. That’s a fundamental piece of the puzzle.

To your second point, how does an organization reduce their liability or risk if somebody were to breach their system and get access to this data? Obviously, if you have lots and lots of research data sets that are lying around that have identifiable information, the more identifiable information you have, the greater the risk. If, however, you have those data sets that have been de-identified, but it’s still possible to link them together even within your own institution, there are organizations that use that as a way of helping mitigate the risk around research data and still make it useful to people, because it’s not as if you’ve de-identified it and now it can only be used for one purpose. You can de-identify it, but by making sure you’ve got those tokens, you can still then reassemble different kinds of data sets for different purposes as long as you’re being very careful that the risk of re-identification remains low.

If FDA receives tokenized data that requires urgent follow-up with individual patients, would it be possible for them to go back to the contributing source?

If it’s your data, if you’re a provider and you have data within your electronic health record, you can maintain a look-up table that will have the patient’s identity, your medical record number perhaps, and the token assigned to that as well. But that would be something that an individual hospital would maintain and it would never become public knowledge. So the short answer to your question is, absolutely, if the FDA said, “There’s a safety concern, and we’ve identified within this population that there are specific patients that we need to reach out to,” you can go back to the contributing hospitals and you can ask them that question – “We have some folks, here are their tokens, can you help us identify who they are?” If that organization has maintained that look-up table, then yes, we can get back to those things for those safety needs that the FDA or others might have. That look-up is not something that Datavant does. That would be something that would be within the purview of the owners of the data.

Is there a consistent de-identification method that is being used by all these companies, EHR vendors, and even providers themselves who are selling de-identified patient data?

We take maintaining the de-identification of the data pretty seriously. We provide the ability to remove the PHI and to add in the tokens. But you can imagine, you might have one dataset that is perfectly de-identified and another dataset that is perfectly de-identified, but when you combine them, you increase the risk of re-identification.

Suppose the first dataset has specific diagnostic information and the second dataset has specific geographic information. You combine those two and you might say, we have a geographic area in which there’s only a single diagnosis of this particular disease. That becomes highly re-identifiable if somebody connects some of the dots. De-identification, in and of itself, doesn’t necessarily mean that it can’t be re-identified when combined.

For folks who have complex data or complex linkages, we always recommend expert determination, which is a statistical approach to analyzing the risk of re-identification. You can run a series of algorithms across the dataset that can tell you that you have too much geographic specificity or diagnostic specificity. Given the kind of study that you’re trying to do, maybe we need to aggregate this at a less granular geographic area so that you can still ask the questions that you want about the details of a particular diagnosis. That expert determination is a way of assuring, even if the data has been de-identified or linked to other data sources, that you remain compliant and that the risk of re-identification remains low with those datasets.

What kind of expert performs the expert determination?

There aren’t a lot of rules out there around this. A provision within HIPAA says that expert determination is the statistical approach that has a low-to-no risk of re-identification. Typically, you have academicians who are doing expert determination. It’s really about controlling the release of information in a way that has statistical controls around it. There are companies that do this.

Within Datavant, we have a firewalled relationship with a company, Mirador Analytics, that does this expert determination. They work essentially independently when it comes to the expert determination effect. But it’s offered as a service so that people who are doing this tokenization and then linking have the ability to then, in an efficient manner, determine whether there is a risk of re-identification. There’s a whole host of folks that are out there, from academicians that have a shingle and they do a good job of this, to an organization like Datavant that provides that as a service to folks who use our tokens.

You’ve seen healthcare grow data-rich going back to your days working on Meaningful Use. What issues remain on the table for using the wealth of data that is suddenly available?

The Institute of Medicine had a series of articles going back 10 or 15 years — I think it predates some of Meaningful Use work I did at ONC and has has continued since then – describing this notion of the learning healthcare system. To me, that is a societal goal that I would love to see, where every interaction that a patient has with our healthcare system becomes an opportunity to learn how to take care of the next patient, and the next patient after that, in a better way.

There’s a whole host of problems that we have to overcome to get there. One of them that Datavant is addressing is that when your data gets fragmented and you want to get that longitudinal record, is there a way you can do that that preserves a patient’s privacy?

We have got lots and lots of regulatory frameworks in which your data is used. If you are a student and download your student healthcare record, combine it with your electronic health record information, download it to your Apple Watch, and then use that information on your Apple Watch to support a clinical trial, you will have traversed five different regulatory frameworks. People tend to think that if it’s health data, it must be covered by HIPAA, and that’s not the case. For the data that is in an app or that is part of a commercial venture, it’s that 80 pages of stuff that you just scroll through and you click OK because you want to be able to use the app that defines what they can do with your data. One of the things that we’re going to have to address is getting a consistent way in which we address privacy.

The last thing I’ll say about that is that because there is this notion and there are some concerns that data that is outside of the healthcare environment may need some additional protections that the FTC or that Common Rule or whatever doesn’t necessarily cover, we are seeing a lot of states that are starting to come up with their own privacy rules about how health data gets managed. We run the risk of having inconsistent definitions of what de-identification and expert determination is, and that’s going to create a tremendous burden on the industry and it’s going to create potential holes in which patients’ privacy could be otherwise compromised.

As we begin to solve these technical problems, there becomes other kinds of problems that come up. Keeping consistency across all of the different states, as well as integrating the different frameworks that we have, even at the federal level, becomes important, because if we’re going to use data in this learning healthcare system, we need to have consistent, reliable, and effective means of making sure that patients’ privacy is protected and done in a consistent way.