HIStalk Interviews Blake Walker, CEO, Inbox Health

Blake Walker is co-founder and CEO of Inbox Health.

Tell me about yourself and the company.

Inbox Health is a software platform that fully automates patient billing, payment collection, and patient support for medical practices and billing companies. We try to make bills clear, help them get to patients faster, and make them more convenient and affordable for patients to pay. Alongside that, and an important part of that process, is to make sure that patients get fast and empathetic support via phone, text, and real-time chat to get their questions about their bills answered while we’re doing that.

I started in the healthcare space right out of college. I worked on a patient financing startup and quickly learned how problematic the patient AR problem was becoming for medical practices, especially smaller medical practices. I then spent a couple of years working on another patient billing startup and then ultimately founded Inbox Health 11 years ago. I have been with the company ever since, growing it from zero to where it is today, with about 3,500 medical practices using the platform nationwide.

How does the patient’s payment experience influence their satisfaction with the provider?

It’s a huge factor. It’s so intertwined today, the way the clinical experience then carries over into the billing experience. The patient can leave that visit feeling good about the clinical care, but then have such a bad billing experience that their entire perception of that provider is dragged down. 

If there are mistakes in the way their insurance was billed, the provider may end up getting into an argument with them on the phone after the fact. Or even worse, it’s not even the provider, it’s the provider’s billing service provider. The patient may feel that the clinician provided a worse clinical experience because of how the billing went.

Having a great billing experience is critical to making sure that the entire clinical visit is perceived as positive. So much more frequently than ever, that billing experience is a negative one. Patients owe more money. High-deductible health plans are common now, and patients are surprised by the bills they get and are frustrated by them.

As providers, we owe it to the patients to do everything we possibly can to make sure that the billing is done accurately and clearly and that the experience that they have is convenient. Often it’s paper checks only and poor patient support to answer their questions. That will obviously leave the patient with a bad outcome.

How do practices prevent those awkward financial moments that can start or finish a visit, especially when the practice may not know what services the patient will need ahead of time?

Educating the patient about their coverage at the time of the visit, and how that visit is likely to be billed to the patient, is an important starting point. You don’t necessarily need to have it down to the dollar, just that the patient understands that a bill is likely. If they come in to a nutritionist’s office, their child is sick, and you see that they have a high-deductible plan, give them a sense of expectations, such as that it usually takes about two weeks for us to send bills out. Or after your insurance is adjudicated and we know that you’re on a high-deductible plan, I want to make sure to flag that for you. That’s realistic for most practices with just their standard processes for eligibility checks prior to visit and understanding a little bit about the patient’s insurance. The patient can fill in the rest.

Then, whatever you can do to get the bill to the patient as quickly as possible. You don’t want situations where it’s months and then the patient’s getting a bill 90 or 120 days after they came in to see you. I understand that there’s often trouble getting it through the adjudication process with insurance, but getting that timeline as fast as possible so that the patient is in that same frame of mind as when they came in to see the clinician in the first place. Having that be an easy, convenient digital-native experience as much as possible helps to streamline that whole experience. 

How does the method and timing of presenting the bill to the patient affect getting paid?

Most patients want to have both the digital presentment and also the tactile patient statement in the mailbox to know that it’s legitimate. Sending a text message or an email captures their attention, but it doesn’t feel real to them. Once they get the statement in the mail, then it feels more real and they are more likely to pay from the email or text that follows up after the statement. It’s a combination of demographics and who’s more likely to pay from email or text message than a paper statement. But for most patients, email is the most likely way to drive payment.

No method on its own works particularly well. Everyone pays attention to text messages, but are hesitant to click on them and pay because texts are often used for scams. It has to be a holistic approach, where at least in our case, we’re using artificial intelligence to identify what will probably work best for most patients. It’s all dynamic. It has to be an omni-channel, holistic approach to trying to reach the patient in the way that will work best for them and meeting them where they are at any particular time through a process over several weeks and sometimes months.

How common is it for the patient to need or want to contact someone at the practice once they’ve received a bill?

About a quarter of the bills that go out create a question. That’s obviously a huge factor in terms of how you’re running a practice now. If you’re sending these bills out without anticipating and being prepared to answer those questions, it’s going to pull down your collection rates. It’s going to negatively impact the consumer experience with those bills. Most of us aren’t well prepared to do it, but it’s a high proportion that are coming back to the practice with questions. 

A big factor is the amount of money owed. The average family has a $4,000 deductible and it’s not uncommon to end up with a $500 or $600 bill from a standard medical visit. That’s a huge number for most families. You shouldn’t expect that someone who gets a $500 or $600 bill will just blindly pay it from all of this wording that’s on the bill, and why it was billed that way. It’s unlikely that someone will just pay without asking a question.

What is the outcome of those billing calls to the practice? Are patients looking for reassurance that the number is correct or perhaps wanting more details that could have been provided on the bill initially?

I would say that about half could have been addressed upfront. Better setting expectations, providing better information on the bill itself, is often a root cause of the questions that come through. But a significant number of them are related to how the billing was done. It’s often somehow related to coordination of benefits, meaning what insurance was billed and in what order was it billed, particularly for patients who have multiple insurances like Medicare or Medicare Advantage plans or multiple commercial plans. A lot of those cases have legitimate issues that feed back to it, and ultimately, that could be prevented to some degree upstream just by collecting better information at the front desk.

I’m just isolating the patient billing itself. It’s a little difficult to control what problems land on the lap of your patient support team because something wasn’t done well up front.

How often does the patient get frustrated by trying to coordinate the practice’s billing, the insurance payment, and their own financial responsibility?

It’s frustrating for everyone. The provider obviously wants the procedures to be covered to whatever extent they possibly could be. The patient is stuck in this loop where they’re asking the provider questions, the providers are deferring to the payer, and the payer defers to the provider. All sides don’t have a full picture. 

The patient is the one who’s left holding the bag with a bill that someone is demanding to be paid and the frustration of two parties that aren’t seeing eye to eye. It’s common for the provider’s answer to be “ask your payer” and for the payer’s answer to be “ask your provider.” The patient may finally give up and pay the bill or ignore it and see what happens. Patients are seeking that alternative more and more.

What are some best practices for reducing how long it takes to receive payment for patient responsibility?

Optimizing the number of touch points and the channels that you are able to reach a patient on in that first 15 days is critical. That’s the first thing.

Second is meeting patients, from an affordability perspective, where they are. Understanding where a patient’s threshold is for when they might need payment plan options and making those payment plans available to a patient readily. You don’t want the patient waiting 45 or 60 days, getting three bills from you, and then picking calling you and saying, “I know you keep asking, but I don’t have $1,500. I just don’t.” Then you tell them that you can take $50 a month and that’s fine. You need to be proactive about how you engage the patient, which channels you engage them on, and then offering the payment plans when it’s applicable to that particular patient.

We do predicted payment plan offers, where we’re looking at various data points about a patient, their bill, and their past history with the practice and then determining which ones to offer payment plans to and what kind to offer.

But if you can do those two things well, that will get you the best possible result. Some of this comes back to the more that you do at the front desk to educate the patient and collect cards on the file, the more you can accelerate that back end as well. But if you can’t influence that or change that for whatever reason, then obviously on the back side, that approach makes the most sense.

How are you using AI now and how will you use it in the next year or two?

AI has always played a role in how we manage the outgoing patient billing process. The biggest changes in how we’re using AI, and how AI will be used in the patient experience moving forward as it relates to patient billing, is on patient support. We are investing heavily in making the patient support experience better by training large language models to answer the patient questions that come back, feeding it data from the patient record to be able to help it answer patient questions, and letting it actually take action, such as the patient didn’t get a paper bill and wants one, so AI sends it. Or creating a payment plan.

Over the next two to three years, you will see a transformational change in how patient phone calls are answered and how patient chats are answered relative to where we were a couple of years ago, or a year ago. Or even right now, where most of that is either going to the practice staff in the office or it’s being outsourced to the Philippines or India to lower-cost resources. The quality of AI for patient support is rapidly improving and will play a cool role in improving the patient experience in many ways, but in particular, around patient billing.

What factors will drive the company’s strategy over the next three or four years?

Investing heavily in the role of artificial intelligence in the patient experience is a main focus for us over the next few years. And in general, partnering as closely as we can with the best-in-class EHRs and practice management systems to make the experience as seamless as possible for patients where their providers are using different EHR platforms is really important to us. Those are the areas we’re investing heavily in. We believe there’s a lot of opportunity to improve the front desk experience. That’s another area where we’re focused on trying to build technology to improve how the front desk experience connects back to the patient billing experience post-visit.

HIStalk Interviews Don Woodlock, Head of Global Healthcare Solutions, InterSystems

Don Woodlock is head of global healthcare solutions at InterSystems.

Tell me about yourself and the company.

I’ve been in our industry for my whole career – 14 years at IDX, 15 years at GE Healthcare, and eight years here at InterSystems, where I run our healthcare solutions. These are the applications that we sell to the healthcare industry, which includes an EMR that we sell outside the US and an interoperability data product line called HealthShare that we sell around the world. 

Otherwise, InterSystems is also a data platform company. Most famously, Epic is built on our technology, but about 1,000 other systems have been built on our technology as well. We’ve been in the industry a long time, specializing in data and interoperability, with special skills in healthcare.

How central is healthcare to the overall mission of the company, which has $1 billion in annual revenue and 2,000 employees?

We are primarily in healthcare, where we have a deep focus and experience base. It has been our longest business. Our technology is applicable to a few other industries, so we have built up financial services and supply chain product lines and teams, but our heart remains in healthcare.

We have been foundational, so everybody doesn’t necessarily know our name. We are behind other vendors as the interoperability or data platform for many customers. We’re not always out there with the front-end face of healthcare software, but we’re certainly in there on the heavy duty lifting, performance, and scalability of the healthcare data side.

What are the latest developments in the company’s technology?

We are not unusual in that we’ve been focused a lot on how Gen AI can make a big difference to our products and to our customers’ workflow. Each of our products has had exciting innovations, with new features and modules that are enabled by Gen AI. We are certainly in that AI era, a good AI era, and we’re a couple of years into it.  We have a lot more years of innovation and hopefully making healthcare a lot better with this technology.

What parts of healthcare do you expect to see profoundly affected by AI, especially in quality, cost, and access?

At least the first few years, we’re focused on the user experience and having the use of technology like ours, like EMR, be a whole lot more fun, delightful, natural, and more human to use. We moved to graphical user interfaces 20 or 25 years ago. We thought that was a big shift, but it’s still hard to use. It’s still a lot of pointing and clicking, dropdowns, and tabs. It’s not a very natural experience.

With GenAI and approaches like ambient or natural chat user experiences, we will be able to create software that’s a whole lot easier to use, to get information out of, and have it pay attention to our instructions and do useful things for us. Historically, software has been kind of dumb. It follows the instructions of the user, stores the information that I type in, and then shows it back to me a few days later when I ask for it again. AI can allow us to build a lot smarter software that will be more helpful to us as users and hopefully will help transform the industry.

We first focus on the user experience. Down the road, we’ll start to move into other areas around clinical decision-making, workflow optimization, and a better patient experience. There’s a lot of places we could go with this technology. 

You just announced IntelliCare, a next-generation, AI-centered EHR that is available only outside the US. What were the lessons learned in developing it?

We took a bet that worked out, which is that AI should be natively built in the EHR versus just a partnership with somebody else. That’s really working out. It’s enabling us to do closer integration of the technology into the workflows of the user instead of having it be an arm’s length relationship. That’s been good.

It takes more R&D to do that. We’ve had seven teams working on this across our EHR development teams. With enterprise EHRs versus best-of-breed departmental systems, enterprise has won out as the right strategy. I don’t think that AI is that different. You want to embed it into that enterprise feel versus having it be a best-of-breed type system. We made that decision early on that we would do this natively. That cost us more, but I think it’s going to pay off, and it is already paying off with some of our early adopter sites.

Other lessons learned with AI is that it’s important to work closely with our customers. There’s a lot of trust issues with AI. There’s a lot of education issues in terms of how these systems work, how we test and validate them, and how we get comfortable with the way that our data is handled by a cloud AI provider.

There’s a lot of new ground on the InterSystems side, but also on the customer side in terms of governance, legal, safety, and a comfort level with AI overall. We’ve had to spend more time than I would have guessed on the customer side, educating them and getting them comfortable with what we’re doing. Maybe part of my education push on AI was observing how much the market needed to learn about AI in order to adopt it well. We’ve just encountered a lot of that with our early sites.

How does traditional software development, maintenance, and support change when you add an AI component?

The good news is that all of these large language model vendors basically use the same APIs and the same way to call them. There’s not a lot of technical investment that you’re making in one road that’s not useful for another road if people continue to leapfrog each other and things change. 

What is really tricky is the testing and validation process, because when you are dealing with generative AI and you ask the same question multiple times, you’re not going to get the same answer back. There’s a non-deterministic aspect to the way large language models work, even on the inbound side. If somebody’s asking a question about a patient chart or whether they have been seen for this condition before, there might be multiple ways that that clinician might ask essentially the same question. There’s non-deterministic aspects on the user side and then certainly non-deterministic aspects on the answer side. 

We had to invent our automated testing process and our validation process from scratch. That is much different than our traditional process, where we want them to fill out these four dropdowns and get the answer “32” in the end. For this non-deterministic process, we’ve had to build up a completely different automated testing infrastructure and validation infrastructure. We have a lot more human validation with real physicians and nurses in the process. Testing, measuring accuracy, and then maintaining that accuracy as the model providers come up with new versions is a whole different design and architecture that we needed to build around this.

How are you using AI tools personally?

We provide our employees with OpenAI licenses with an enterprise agreement, where they can use it for company confidential stuff. We’re enabling our employees, myself included, to use and take advantage of the technology.

For me, I use it most for coding side projects. I do a lot of AI side projects just to keep current with the technology. These large language models are excellent at writing code, answering technology questions, debugging, and stuff like that. It’s remarkable how well these technologies work as maybe junior programmers or code developers along with you. 

One way to view these AI technologies, at least for the next couple of years, is for empowering every human employee here with a co-marketer, co-developer, or a co-implementation person who can help them be better at their job, be more productive, debug problems faster, and that kind of thing. 

The industry could use basic AI education to navigate the opportunities and risks with AI effectively. I’ve always enjoyed teaching, so I am doing five or 10-minute videos called “Code to Care” to explain AI concepts. I always have enough content because buzzwords are being thrown out that people don’t understand or that vendors overuse. I am enjoying putting together that AI education. It’s important. HIMSS, HLTH, and ViVE have a lot of sessions where educators don’t get into enough depth, or maybe they don’t know enough depth, to help you understand some of the newer topics and approaches.

I don’t know if it’s to the company’s benefit or not, but I certainly enjoy doing it. I enjoy hearing from people across the industry who have known me over the years who like my video content. It’s important that we navigate this AI wave effectively.

What has been the impact of moving to the cloud?

I’m finding that our customers are struggling with anything on-prem these days. Maintaining a data center and keeping hardware and storage current, updated, and patched for security vulnerabilities is a growing challenge. More and more of our existing customers are asking us to host their platforms or offer the same functionality as some kind of service or equivalent. 

For our net new business, we almost do everything as a service. People within health systems and payers don’t want to be doing this anymore. It just doesn’t make sense economically. It’s the predominant model that we find to make software and technology available to customers. We do the heavy lifting, such as maintaining the staff, buying hardware if we’re doing it ourselves, or procuring it from one of our cloud partners. The industry is just kind of done with on-prem software and relying on their software vendors to manage it as a hosted or software-as-a-service platform.

Is interoperability a solved problem?

[Laughs]. No, no, no, no. I definitely think that the ball has moved, which is great. When I started in interoperability, the use case was a provider seeing a patient, let’s say in the ED, and wanting to know what happened with this patient outside of my health system. That is getting solved. National networks like CommonWell or vendor networks like Epic’s Care Everywhere have done a fabulous job with that use case, and the ball has moved.

But we’re trying to do new things. We are working hard on the payer-provider interaction, like electronic prior authorization, clinical data exchange, payer data exchange, and patient and member access to their information. Those are new exciting use cases that we’re working on as an industry.

The industry still struggles. We are in the middle of this with our technology and services with mapping data in one format and making it consumable and useful in another format. So it’s definitely not a solved problem. We are enjoying a great growth of FHIR as an approach and a set of standards, and that is helping with all of these new use cases. 

Things are getting better. We’re moving on to slightly more advanced problems from an interoperability point of view, but it’s certainly not a solved problem at all.

What near-term trends will influence the industry and the company?

InterSystems has been around for 47 years. We have a slide that we talk about, which is the advent of micro-computing, PCs, the Internet, cloud computing, and now Gen AI.  Each of these is maybe a 10-year-long transformation that has allowed us to do great new things. All of those significantly advance the impact that computers and software have had in healthcare. Gen AI is going to be either no different, or even better, than some of those prior transformations. That’s a terrific trend. 

I also think that cooperation among payers, providers, public health, Medicare plans, and others within a community is getting stronger. It will make it easier as a patient and as a caregiver for your family to navigate the healthcare system. I hope that technology, interoperability and cooperation across communities will continue to improve. I certainly see it improving with customers that we work with.

HIStalk Interviews Anthony Lucatuorto, CEO, Sphere

Anthony Lucatuorto, MBA is CEO of Sphere.

Tell me about yourself and the company.

I’ve enjoyed a 25-year plus career in the fintech space, with leadership experience in embedded payments, digital engagement, and high-growth partnerships. I began my career working at Mastercard and American Express in the early 1990s and held executive roles at First Data, TransFirst, and TSYS before arriving here at Sphere, Powered by TrustCommerce in 2018.

TrustCommerce is a financial technology company that provides secure, integrated healthcare payment solutions to some of the largest health systems in the US. We’ve been doing this for over 25 years. More recently, we are proud to have launched our next-generation card present payment solution, called Cloud Payments, that advances our EHR integrations and continues to help make the patient payment experience more seamless, flexible, and secure.

How are providers supporting newer payment methods and technologies?

Collectively, the industry is on the right track. We need to implement it with what I always preach to my team, which is a quicker speed of play. The act of paying for healthcare is just different than in retail. We need to continue to ensure price transparency, educate patients on their responsibility prior to treatment, and provide patient billing plans. We need to capture cards on file, along with an account updater tool that helps keep our tokenized card information current.

Over 50% of private employees in the US who participate in medical care plans are enrolled in high-deductible plans, according to the Bureau of Labor Statistics. These deductibles keep getting higher year after year. Embracing technology like digital wallets capabilities and recurring payment tools are great examples of ways that providers could help collect more of the growing patient responsibility.

How does healthcare compare to other industries in that regard?

If you or I have a retail-like experience, we take for granted that it comes with speed, convenience, transparency, and trust. The healthcare industry is catching up to this. The industry is a little bit behind, but is now providing more advanced omni-channel payment options, more payment methodologies such as Venmo and PayPal, and more digital wallet products like Apple Pay and Google Pay. These are great examples of ways to get closer to what the patient experience needs to be, which is what they are experiencing on that retail side.

Are providers generally accepting patient payments from Venmo and digital wallets? Is use of those methods skewed to a particular demographic?

It’s funny that you say that. I’m Gen X and I don’t know how many baby boomers are using these, but my generation certainly has embraced it. Millennials and Gen Zs are certainly embracing Apple Pay, Google Pay, and all of the digital wallet products very well. They are after speed, convenience, transparency, and trust.

From the provider side, you have to do that in all of the omni-channel payment options. Whether it’s at the point of sale, in front of your doctor’s office at a kiosk about to check in, or you go online, all of these omni-channel payment methodologies need to accept these forms of payments. More and more, they are.

How are virtual credit card numbers and tokenization being used?

More and more of our clients are capturing tokens. In fact, in our experience, over 70% of healthcare organizations offer patients the ability to store a payment method, and that’s super important. Providing an account updater tool is important, so as a card expires or gets lost, you’re constantly updating the information. Keeping that tokenized card on file helps the provider collect payments today for the future, post-treatment billing down the road, and recurring billing options.

There’s a wealth of opportunities for them. It’s a growing tool and product and providers are certainly starting to embrace it.

For that virtual card question, we’re discussing this a little bit more than we used to. It’s more on the insurance side at this point, where insurance companies send a virtual card to providers. It allows the provider to collect quicker and maybe with more enhanced data for their reconciliation. However, it comes with a cost, because now you’re introducing card brand fees and acquiring fees, which the providers wouldn’t have had with just an insurance payment. Providers absolutely have to weigh the cost benefit of these virtual cards.

What do pre-arrival financial activities look like?

We don’t see payments as a standalone event that always happens at a certain time. The payment needs to be woven in throughout the patient’s journey, complemented by all the tools that are available to help the patient know what they owe, why they owe it, and who they owe it to. Then, to set them up for the best chance of being able to pay their bills. Patients don’t know or care that the appointment reminder system might be a different company than the scheduling system or the patient billing system.

Providers that are being successful in this area are the ones that step back and think about the entire patient experience from beginning to end, giving the patients the right information at the right time to take the right action. That’s really the key.

How does EHR integration work?

We focus on helping our providers collect payments. We are super proud of the fact that we’ve been integrated into Epic, as a great example, for more than 15 years. We’ve done so in all of their native workflows. 

From a provider standpoint, we are embedded in all of the workflows of the EHR, Epic as a great example. They see that as a great experience and greater opportunity to collect payments. It becomes more streamlined workflows for the provider’s patients. It allows centralized reporting for analytics across locations. On the patient side, they have greater information, which is greater cost transparency, and simpler flexible payment options. It’s all within the native workflows, which helps make reconciliation seamless.

How are providers implementing propensity to pay and payment plans?

Most of all of those tools exist in the EHRs, so from my vantage point, I’m making sure that my solutions are embedded into all of those collection points. When they get that that pre-estimate, if they want to make a payment, I’m providing the tool and the access for that provider to collect that. If they want to wait until after service, I’m providing the tool in that omni-channel environment to make that payment. I’m making sure that all payment methodologies are captured, whether it’s Apple Pay, Google Pay, Venmo, PayPal, or ACH.

How will AI impact your business?

It’s growing exponentially. I expect it to play a larger part, exponentially, quite honestly. We’ll see it in the service side. We’ll see it in our development side. It is exciting and we’re absolutely diving into it and analyzing everything we can.

What will be important to the company over the next two or three years?

We are going to continue to advance our products so that they remain on the cutting edge of being seamless and secure. It always starts with security. We’re going to make sure that we know where the puck is going as it relates to whatever is the next form of card payment. What’s the next Venmo or Apple Pay that’s coming around the corner that the next generation of payers want to use? We’ll make sure that we invest in that technology.

We see healthcare providers heading in the right direction. We’re happy to be a part of it. To summarize the ways that they could continue to help build a path to better collections of patient payments, continue to think of the journey from beginning to end of the whole patient experience. Provide those cost estimates upfront, support the flexible payment methods, provide those omni-channel payment options, ensure that the secure payment storage for future treatments and recurring billing, and continue to communicate early and often. That’s the best thing we can do.

HIStalk Interviews G. Cameron Deemer, CEO, DrFirst

G. Cameron “Cam” Deemer is CEO of DrFirst of Rockville, MD.

Tell me about yourself and the company.

I’ve been with the company for 21 years, as CEO for the last two and a half years. I started my career in the ministry, where I worked many years with churches in Arizona and did some time in Papua New Guinea working with Bible translation. I got into healthcare IT totally accidentally during the recession in 1992, when I came back to the US. I grew up here in the PBM industry. I worked for the old PCS Health Systems in Scottsdale and then building what eventually became Surescripts while I was at NDC Health. I have been with DrFirst ever since.

DrFirst is celebrating its 25th anniversary this year. It has been a really interesting ride. The company was originally founded to eliminate what I would call technology friction for the doctor. I was the first product manager for this little 30-person company when I came here. The CEO and founder, Jim Chen, sat down with me and said, “Look, Cam, you need to understand one thing. Here’s what I need you to do. I need you to make sure that DrFirst is number three in the e-prescribing space. That’s your target.”

I was like, “Why would you want to be number three?” He said, “Any industry always ends up with three players. I don’t care if we’re number one or two, I just want to be number three.” With that challenge, I started my career at DrFirst. 

We have developed a huge footprint over time. We are handling scripts for about 550,000 doctors a quarter. We provide the e-prescribing back end for 275 EHRs. We are actively engaging 6 million patients a week for various programs, most of them adherence related. We have always been an innovative company that is trying to solve what we think are the real, gritty problems in healthcare.

You said in a recent article that the pharmacist’s role in patient care was limited by the original design of the electronic prescribing network. Do you see that changing, particularly given the struggles of the drugstore chains?

When I joined PCS in 1992, the company was already experimenting with e-prescribing. They were doing some of the early seminal work of getting some doctors to use the system. I believe at the time that they were using email to send prescriptions to Walgreens, and then the pharmacist would pick it up from the email. In those days, there were a lot of early attempts to do e-prescribing in different ways and PCS wasn’t the only company involved. That was eventually all destroyed by a patent troll who went through the industry suing everybody. Then that industry had to reinvent itself. 

While that was all going on, PCS selected me to be their representative on the script task force at NCPDP when it was first put together. I was one of the three original co-chairs working on SCRIPT 1.0 and continued to be loosely involved with e-prescribing at PCS. I was thrilled to death when we announced the creation of RxHub in collaboration with ESI, Medco and PCS at the time. We built that system based on technology that already existed, the pharmacy claims switching technology. 

It made all the sense in the world. The PBMs had already transformed pharmacy, and healthcare IT around pharmacy, by fully digitizing the claims process. It worked great. We went from paper claims to terminals and then PC or mainframe-based transmission of claims through a central switch. It was great, so you can imagine that when they turned their attention to e-prescribing and said let’s digitize that, they had every belief they could do it. They had what they believed was the right technology, and they built it. 

When Surescripts saw what was happening, they decided they had to do the same thing and not let the PBMs cut them off from the doctors. So they also implemented e-prescribing based on claims switch technology, which I had been helping develop while I was at NDC Health. When I came to DrFirst, RxHub was already there. Surescripts was already there. DrFirst was working to get the doctors to adopt e-prescribing. None of us had any time to really think about it.

This just seemed like the right solution. It did what it was supposed to do. It let 600 participants on the EHR side talk to 600 participants on the pharmacy side and solved that many-to-many problem. It converted the prescription from writing into a digital format so it could be picked up on the other end and imported into systems. It accomplished its goals. 

We are 20 years down the road now, and it is just now that the cracks are starting to show, as people are saying, “This doesn’t quite work right. This isn’t quite what we need.” It has become a real cap on innovation in the industry, the way the e-prescribing network works. Fundamentally, the problem is that it’s a technology that was designed for pharmacy claims.

A pharmacy claim is a financial instrument. It’s a request for reimbursement from the pharmacy, an accounts receivable, essentially. It goes to a PBM, who runs it against a contract in the adjudication process and promises to pay. They send back an accounts payable transaction to the pharmacy so they can reconcile that to the accounts receivable that they sent forward. So it’s basically two participants, a pharmacy and a PBM. It’s based on a contract, and it’s a mathematical process. There’s nothing more to it than how it matches against the contract.

Prescriptions are totally different. A prescription is a clinical order, not a financial instrument. It is initially ordered by a highly trained clinician who has evaluated a patient, considered their current problem, their ongoing problems, their other treatments, and the other medications they’re taking and then making a decision based on what they know about that patient. Not just clinically, but also all the other factors, such as what they can afford and what they are willing to do.

Then they send that clinical order to another highly trained professional at the pharmacy, who would like to be able to evaluate that, add their thinking to it, and interact with the provider who wrote the script in case something needs to change. Eventually that’s filled by the pharmacist and the patient needs to pick it up, so the patient is another participant here who maybe doesn’t know whether their prior auth has been approved, whether it’s ready at the pharmacy, and how badly they really need it.

There’s a lot that the patient also has to think about through this process. There’s also pharma, who really, really, really wants the drug to be filled at the pharmacy once it’s written. And there’s of course the PBM, who’s interested in getting as clean a script that ideally matches what they’re trying to do with the patient as well. You have five key participants in this process, all trying to work around a transaction that is flowing through something that was designed for claims, and it just doesn’t work. 

The biggest failure point is that the script arrives at the pharmacy with no context. The pharmacist can’t really do their job, the job they’ve been trained for, because all they get is the digital version of the script. We’ve been taking a look at that for many years. It was the recent FTC settlement with Surescripts that opened the opportunity for other networks to enter the market, so we have introduced our version, which includes the ability to carry the extra data needed with the transaction to establish rule sets by which we can manage workflow issues.

For instance, some scripts get to a pharmacy that the pharmacist is never going to be able to fill, so they have to call the doctor to get clarification. We can handle that on the front end, just based on a rule that says if you get a script like this, ask the doctor to correct it in these ways before it actually goes pharmacy. It saves the doctor a phone call, saves the pharmacy a phone call, and the patient has access to therapy more quickly.

The solution is freeing up the clinical order to be a clinical order and to have everything it needs to be processed without a lot of friction at the pharmacy.

Early e-prescribing was done on a standalone PC or terminal. How has it progressed to integrate back into the EHR?

You raise a good point that initially e-prescribing was standalone. Now it’s fully integrated into the EHR. It’s just part of the standard EHR workflow. 

What’s been done over the last several years is bringing more of the information the doctor needs to make a decision into that system. One is real-time benefit check, where you’re doing a pre-adjudication of the script to give the doctor an idea of what the impact will be on the patient when they show up at the pharmacy and having to pay for that prescription. Also giving the doctor the same information on alternative drugs that would also be applicable under the therapeutic class so the doc can make a more informed decision based on plan design. That has helped people avoid prior authorizations, so that the doctor can see one drug that requires prior auth, so I’ll go with the one that doesn’t. Along those lines, information about the patient’s plan has been useful.

What’s coming now is more information about the prior authorization question sets that the doctor needs to answer ahead of time. The ability to grab that information from the EHR and send it along with the request for the PA so that you don’t have to have back-and-forth between the doctor and the PBM to get the PA approved. A lot of what’s happening now is pulling information into the doctor’s office that would avoid them having to have phone calls or electronic back-and-forth with pharmacies or PBMs.

How are you looking at AI?

We definitely don’t believe that just slapping a chatbot on top of our existing stuff counts as AI. We’re actually trying to take a much deeper approach to it and go at it from three levels.

Probably most important and foundationally, we’re trying to train every single person in DrFirst to be comfortable with the concepts of AI. Comfortable with interacting with it to help them develop individual visions around how AI can be used to automate processes at the company, as well as be incorporated into our products to improve workflow for other people. So we’re starting with our people first. We move it then into the feature set of our products to make workflow better for the folks who use what we do. In other words, it becomes a feature.

We are just now starting to work on an actual product that is completely AI based. For us, the most important applications of AI are practical. We’ve been using it, actually for quite a while, for interoperability solutions that are e-prescribing. We’ll continue to expand focusing on AI’s ability to help people get work done quicker with more information and fewer redos and stuff like that.

What kinds of medication-related engagement do patients want or need?

Some interesting things are happening right now. Consumer engagement is really hot in healthcare. It has been interesting to watch how that is expressing itself out in the wild. This is one of the areas that we’re intensely interested in, but I probably should have said this earlier. We like to think of ourselves as productively contrarian. It doesn’t matter to us so much what other models are being built right now. We are more interested in what’s the right way to handle the situation. 

If you think about what happens with patients today, there’s a lot of activity around patient choice of pharmacy. What if the script is written for a patient, and then for some reason, the patient wants to go to a different pharmacy? I’m going to be passing this pharmacy on the way home. I’d rather pick it up there, or I found that I can get a consumer card that would be cheaper at this pharmacy than that pharmacy. There’s a lot of talk of use cases like that that aren’t really all that interesting because they’re probably fairly rare based on how people tend to develop habits and how they pick their pharmacy in the first place. I usually think of that as trying to come up with a solution where there’s no problem.

But there are other more significant things. Patients who have important drugs that they need to receive, but the script has been written to the wrong pharmacy. For instance, a specialty drug that has a limited distribution network is sent to their regular retail pharmacy which may be reluctant to give it up, because if they can special order the drug, they can probably make a decent profit on it. But the patient’s going to have to wait much longer than they would if it just were going to the right pharmacy in the first place. Being able to alert the patient that the drug has been sent to a pharmacy that can’t fill it for them immediately is an issue.

Another example would be that the patient shows up at the pharmacy and the pharmacy says, “We don’t have that in stock. Give us until Wednesday and we’ll have it.” The patient may not want to wait till Wednesday and they need to have it filled at a different pharmacy if they can find one that does have it in stock. The ability to switch that script without having to rely on the pharmacy being willing to give it up, or a doctor being willing to rewrite the script to a different pharmacy, that’s all friction from the patient side.

You see a few different solutions in the industry. For instance, having the doctor write the script to a company that will then show the patient on an app that they’ve downloaded that a prescription has been written for them, then giving them a choice of pharmacies so the patient can pick a pharmacy. Another model might be to persuade the doctor to write the script to a non-dispensing pharmacy, which would then determine the best place for the patient to fill it and then reach out to the patient in different ways to give the patient the option of which pharmacy to use.

These solutions are pretty hot right now. There’s a lot of talk about those. But they suffer from the fact that they require everybody to be out of workflow. The doctor has to not use the default pharmacy, they have to write to a pharmacy that’s not actually going to fill the script, but it’s going to get the patient to fill the script. The patient has to download something and go through an extra step , where otherwise they would just show up at the pharmacy. The physician is out of the workflow and the patient is out of workflow. Typically the folks that are doing these kind of models struggle with volume, and no wonder since everybody’s being required to do something unusual.

Another dirty little secret is why, in the early days of e-prescribing, NCPDP picked this model instead of a more European model, where the script would go to the cloud, the patient would just show up at whatever pharmacy they wanted, and the pharmacy would pull it down from the cloud. That was actually considered in the early days of the SCRIPT standard, and it was promoted at the time by a representative from the University of Alabama.

I remember the meeting where this happened. Everybody else in the meeting disagreed with that approach because they were trying to solve for the adherence problem, that patients are given scripts and are then trusted to deliver that piece of paper to the pharmacy. That creates one more barrier for the patient actually getting the script filled. The pharmacist isn’t doing their job, the doctor’s not getting the results they want, and pharma certainly isn’t getting revenue from the drugs being filled.  So instead, they decided to have it sent to the pharmacy. That will set up an expectation in the patient. They need to go pick it up. It can create a little work for the pharmacist because if the patient doesn’t show up, they have to return it to stock, which is a pain in the neck. 

Nonetheless, it has worked really well. It did in fact improve adherence dramatically. Patients are much more used to picking up their drugs now than they used to be. When we go to a model where the patient becomes the delivery mechanism again, you’re just stepping back into the past to a time when compliance was happening at a lower rate. First-fill adherence was lower than it is today and patients weren’t getting on therapy. We believe the right way to do this is to keep it all in workflow. Let the doctor write the script and let the patient interact with the physician directly whenever the script can’t be filled for some reason. Don’t force the patient into making a selection if they don’t want to make a selection, because if they don’t make one, nothing happens. Make sure the script still gets to the pharmacy.

What will be most important to the company over the next two or three years?

Number one is that we are reinventing the e-prescribing platform. We’re going to give the industry what it deserves. Doing that is very important to us.

We are working to eliminate all the points of friction in the specialty drug workflow. That will become increasingly important with new developments in medicine.

Those are the two challenges we’re taking on right now.

HIStalk Interviews Guillaume de Zwirek, CEO, Artera

Guillaume de Zwirek is CEO of Artera.

Tell me about yourself and the company.

My name is Guillaume de Zwirek, which is a funny name. I was born in Canada. My mom was a physician, my dad was a software engineer, and somehow I turned into a blend of both of them. That’s surprising, right? I turned into a health tech entrepreneur.

I founded Artera 10 years ago, so we just celebrated a decade. I founded it out of personal experience of having to navigate a complex healthcare condition, having to coordinate all of my care by myself. I was frustrated with the status quo, the present state of doing everything on the phone. I didn’t feel like I was a customer, but rather just a cog that came in for a visit, revenue was booked, and I was sent on my merry way. I felt like we could deliver tech that could bring some of the relationships back to healthcare.

What relationship do people want with a hospital or health system? How do you measure the clinical and business value of those relationships?

I never went to business school, but the train of thought that most people are familiar with is that you can do two out of three things, the iron triangle. You can win on service, you can win on quality, and you can win on price.

We think that service is one of the most important things. Relationships are really, really important. They connect us to people. They are the foundation of trust. Especially in an industry like healthcare, when you’re vulnerable and conditions may be life-threatening, it’s important to you know who is caring for you. That flows all the way through from the physician at the top of the pyramid through to the folks who answer the phone and help you get coordinated to the right resources.

From a foundational level, humans want to connect. They want to build trust. They want to build relationships.

Dentistry is a great example. My brother is a dentist, and he shared an interesting anecdote with me. He bought a dental office, which is what most dentists do when they go into business. I asked him why it’s so easy to get funding for a dental practice when the dentist will change and you would expect most patients to leave. He said that I would be surprised that while he spends five to 10 minutes with the patient, the hygienist spends 30 minutes, and people don’t ever want to leave their hygienist. 

You can extrapolate that thought to all of healthcare. If you think back on your best experiences, you knew the person, you trusted them, and they were caring for you. That’s what we’ve been doing for 10 years. We’re only part of it. We are the technology that the people have to be bought in on the other side. But it creates unbelievable connection and loyalty.

As a personal example, I once complained to a solo PCP because her front office staff were clearly incompetent and unfriendly. She urged me to call the practice after hours to avoid them because they would be gone and she would pick up herself. Can technology solve that or does the underlying problem need to be fixed first?

It’s both. The tech can help with monitoring your staff. We released a new product recently, a homepage, which is pretty simple concept. But it highlights how staff is doing in our tool. Are folks productive? Are patients happy with their experience? Are they waiting a long time for responses when cases get routed to a live agent? 

This has been helpful for our customers because they can see where things are going well, and where things are going poorly. They can do coaching on the operational side. So we’ve definitely seen ourselves extend more to the operations.

A lot is changing in tech, like agentic AI. Do we need as many humans as we used to, or, or can these digital employees do the job better? I think the jury is still out on that, but there’s a fundamental technological shift happening right now in the world, but also specifically in healthcare.

Describe agentic AI and how it will be less frustrating than the phone trees of old, where the patient’s time and patience were valued less than preventing them from talking to a human.

The key word in agentic AI is agent. By agent, we mean agency, the ability for an AI to complete a task on behalf of a patient. That is the key condition, the product.

When you think about a generic AI solution, there’s actually at least six underlying technologies that make that possible. Most people probably think about the phone and being able to talk to a digital human just as you described. The alpha version of this technology dates back over two decades, which is what you were describing, a phone tree. Press 1 for Spanish, press 2 for English. That technology is known as dual tone multi-frequency. That technology is dead. That was Version 1.

Version 2 was natural language understanding, which was, please say “one” or “yes” if you would like to continue in Spanish. The patient could respond and say si por favor, ad we would understand that to mean yes and effectively means 1 and then we would continue them down the tree.

With agentic AI and with LLMs under the scene, we can ask open-ended questions, the patients we can respond, and the AI has agency to interpret what is being said and route them down the right path. That right path might be a skill, like resetting a portal password or canceling an appointment, or it could be a skill like routing that patient to a live human being because the agent is not capable of fulfilling that task. The technology has completely transformed.

I have yet to call a health system truly using agentic AI, that final version that I described, but the technology is there. I think for good reason, healthcare should be cautious. You do not want LLMs hallucinating and giving patients bad guidance.

But I think we are on the cusp of a good chunk of the telephonic volume going to these agents, because they can perform tasks more accurately and more quickly than a human can. That will free up our existing staff to focus on the high-acuity cases and building those relationships that I just described, those real, human-to-human relationships that engender trust and loyalty with your provider.

I assume that much of the volume of abandoned calls involves scheduling, which can be complex due to the patient’s primary preference of date, time, location, provider, or soonest visit. How can AI improve that?

Scheduling is by and large the highest use case for call volume. We process nearly 3 billion interactions a year and scheduling is more than half of the inquiries that come into our system.

The interesting thing with scheduling is that we have standards that all the EHRs comply with, and many have FHIR scheduling endpoints. The problem is that those are unusable in practice without the rules you just described that.

There are not only are patient preferences, there are provider preferences. Let’s talk about orthopedics. You can’t just schedule an appointment with any orthopedic surgeon willy-nilly. They have specialized focus. Some may work on pediatrics or adolescents. Other may work on hip replacements, but only for a specific gender. Those preferences get really, really complicated. 

We have a ways to go on the scheduling side in terms of standards. It’s nice that we have the FHIR standards, but without those preferences on top of them, it is hard to deliver fully end-to-end autonomous self-scheduling with an agent. Kyruus, DexCare, and Radix are solutions that provide that filtering logic. The EMRs have started doing this, too. I’m hopeful that those folks will start exposing their APIs, because we don’t want to have to go out and build that logic again on another system.

How important is it that AI products integrate with existing systems?

Before we get to integration, let’s talk about the underlying tech. It’s a complete commodity. We believe that the underlying infrastructure has been commoditized by the big players like Meta, OpenAI, Google, Anthropic, and a bunch of other vendors under the hood.

With AI technology, it is not hard to build an alpha prototype. That’s why you see three-person companies raising a ton of money. We don’t think there is a durable advantage in the technology alone. We believe that the market will shake out in a way where three things will be important to hospital and physician group buyers.

One is that they will look to their existing vendors first, so it’s distribution. Second is content. Do you understand our workflows? Do you have an easy button for turning our documented business practices into autonomous agents? Third, to your point, is integration.

Integration is going to favor folks who have distribution and market share, because they will have connected into a lot of different systems. They will have connected into every EHR. They will have gone deep on their APIs. They may have gone to third parties. But integration in itself is not a durable moat, because anybody can do it. We have a lot of open standards. Integration is critical because the agent needs to be able to perform actions, so full stop. But that is something anybody can do.

I actually think that what is going to shake this market out more is distribution, because it is so easy to build. The folks that build it into their products quickly in a very cost-effective manner and make it super simple are the ones that are going see the most traction.

People have a lot of options when choosing a way to communicate, and many of them seem to least prefer talking to a human on the phone. How do you address that as a business in terms of preference for texting versus calling?

It comes down to patient preferences overall, and it’s not always patient preference. It’s also socioeconomic. Do you have access to a smartphone? Is there somebody who speaks your language on the other side of that text or the other side of the phone? We need to meet patients where they are.

I think the right strategy is omni-channel. It’s multimodal and allows patients to gracefully switch from one modality to another. We talked about dual-tone multi-frequency technology, or DTMF, the phone tree where you’re pressing 1 and you’re just trying to get to an agent or you’re a yelling “agent” at the phone. Poor implementation of automation or AI is worse than just having a human in the first place. 

The right balance, in my humble opinion, will always include humans and AI. I do think AI has the ability to complete tasks faster. I do still think I think there will always be a yearning to talk to a human being when it’s appropriate. So I think it will be a combination, and that’s what we’re seeing from our customers. It’s going to be text, it’s going to be phone, it will be video. In some cases, there’s a combination of all three. Strategically, folks should think about how to bring all three of those things under either a single vendor or a consolidated tech stack to be able to manage those graceful transitions, including language.

There are other dimensions beyond channel that are going to be important to serving patients effectively. I’ll give you an example. For most companies, AI over the past couple of years has been a solution in search of a problem. A lot of people have spent a lot of money and launched a lot of experiments.

One experiment that took off for us more than we expected was translation. It was as a copilot, just a button in the UI. We looked at the patient’s preferred language and we auto-translated communications coming in from the patient into English, so that any staff member could read them. Then when the staff member responded, I could say, “Tim, nice to hear from you. Yes, I have scheduled you for lab work next week.” When we sent that message, we would auto-translate it into the patient’s preferred language.

You wouldn’t believe how popular that has been. A simple tool, very easy to build. So again, the advantage isn’t the technology, the advantage is we have 50,000 call center and back office agents in our application every single day, and they were all able to use it immediately. There’s nothing new to buy, there’s no net new integration, they just automatically were upgraded into capable individuals who can speak 100 languages. 

How hard is it for a health tech business to stay on top of the daily changes to LLMs and also make sure they don’t negatively impact your product?

You have to be experimenting with every cloud service provider at all times. We have simulations in Azure, Google Cloud Platform, AWS, and OpenAI. We are running experiments at all times in all four systems.

I’ll give you a tactical example. The biggest issue with an AI voice agent today, a robot you talk to on the phone, is latency. By latency, I mean, when I say something, how long does it take for the AI to respond? A natural human conversation is not going to be more than, I don’t know, 1.52 seconds. Most of those agent take much longer, which is way too long. You can tell, and it’s a frustrating experience. 

The technology behind that that slows things down is converting speech to text, then making an API call to the LLM, then the LLM returning text that you turn into speech that you read back to the patient. All of that adds a lot of delays. Literally two weeks ago, a new technology was introduced by OpenAI called speech-to-speech, where you don’t actually need to convert anything to text. The LLM is doing all of that natively, which significantly reduces latency.

The day that was announced, we had an experiment running and we were benchmarking the latency against our other system. Every single week, new tech is coming out. We need to understand, does it meet our HIPAA requirements? A lot of the experiments we run, we would never take to production because they’re not ready.

Second, how is it fundamentally going to change the way the software is built? It truly is, if not weekly changes to the underlying infrastructure, daily changes. That is dangerous for people in the infrastructure layer, because investment that you might have spent tens or hundreds of millions of dollars building can be wiped out overnight when one of these large providers releases an update.

What concerns and opportunities for the company do you expect to see over the next couple few years?

We’re in the business of customer service. I try to ignore the noise of what’s going on in the markets, with competition, and other other things in general. How can we make this experience incredible? How can we make the healthcare experience the best experience that the customer, the patient, will ever go through? We are always looking at new technologies. We are patients ourselves. We talk to patients. We talk to providers. How can we make that world class? 

There are advancements that are ready to be taken advantage of by healthcare providers. We talked about one a lot today, agentic AI, but there are others that are even simpler. Branding is one. How often do you get a text message or a phone call from a provider and you have no idea who it is, so you don’t answer. Then you don’t find out what your lab result is. Did you know there’s technology today that allows for branded calling and branded texting? There’s a new protocol, Rich Communication Services or RCS, that Apple just started adopting late last year.

This is all technology that’s available today that can help build that trust. We are focused on being on the forefront of that, deploying that to our customers as quickly as possible to continue building that trust that they have with patients. Our goal is to be that invisible infrastructure layer. When folks work with us, they know that we will be on top of the best technology and the best possible experience that they can deliver to their patients. That’s what drives and motivates us. We will follow the markets and the technologies that come to bear over the next decade and more to come. 

I think fitness as an entrepreneur, as a CEO, comes down to doing the work yourself. I’ve always been in the details. An I building code for agentic AI? No, but could I tell you every single part of our stack? Am I the first person testing a solution? I’m calling agents in French in the morning and I want to know exactly where the technology is. 

That fitness is important. Like if you’re an athlete, you need to go on the track every day and make sure that you’re fit for the next race. As an entrepreneur, as an executive, as a CEO, you have to stay fit and sharp, which means you need to talk to customers every day. You need to understand the tech intimately. You need to understand how you’re deploying to customers. It’s one of the most important parts to doing a good job in business. 

Hopefully you can tell that I love what I do. I’m obsessed with it. I love working in healthcare.

HIStalk Interviews Amanda Sharp, CEO, AdvancedMD

Amanda Sharp is CEO of AdvancedMD.

Tell me about yourself and the company.

AdvancedMD provides a comprehensive technology platform for independent physicians and providers to run their business on. It’s akin to Salesforce, a CRM for medical practices. It includes a practice management, a billing solution, electronic health record, patient engagement solutions, analytics, and payments. The business was founded more than a quarter century ago. It was built originally on the cloud.

I started at the company back in 2006 as an intern in our accounts receivable department. I progressively grew in the company with 15 different roles across finance, accounting, service, sales, strategy, business, and business development before being asked to lead the company in 2019. In December, Francisco Partners bought the company from Global Payments. It’s the second time that Francisco Partners has owned AdvancedMD. With that acquisition, I was named CEO of the company.

Our mission is to empower healthcare professionals to realize their full potential. We provide a platform that helps them do that.

How has the ambulatory software business changed in the past few years?

We’ve seen some consolidation in the past couple of years. We see replacement deals rather than greenfields. They are existing businesses that are looking to replace an electronic health record and a practice management system. We see much more sophistication in the buying process, where people know the gotchas that they experienced previously. We see much higher emphasis on things like cybersecurity, the introduction of AI, and ensuring that the technology solutions are fully integrated. There’s less of an appetite for point solutions, where you have to do a lot of integration work to connect them. That trend has worked in our favor.

Meaningful Use decreased the number of vendors from thousands to whatever it is today. How many can the market support and how much consolidation will occur?

Ambulatory care can support more that on the inpatient side. There are a lot of specialty-specific solutions out there. There are also a lot of solutions like ours that are configurable and customizable to meet the needs of many specialties. AdvancedMD serves 118 different specialties.

I think there’s room for plenty of vendors, but in terms of size and scale that are serving the ambulatory space, you’re at fewer than 10 right now. I expect to see further consolidation over the next several years, whether it’s us acquiring or someone else making some of those acquisitions.

How is the approach of specialty-specific software competitors different?

It depends on the specialty. When you look at something like dermatology, obviously Modernizing Medicine dominates in that space. They have a very anatomical EHR built by dermatologists. For us to compete in that space, we are  partnering with other EHR solutions.

AdvancedMD works really, really well for primary care, behavioral health, physical therapy, and some of the specialties as well. But it really depends on if you need something that’s more anatomical in nature since AdvancedMD is more template based. Also, what systems you need to integrate with.

There’s room for both. The market is huge and there’s tons of opportunity. I don’t buy the notion that independent physicians or providers are going away any time soon. The market absolutely can sustain businesses like AdvancedMD, as well as those that are a little bit more specialty specific.

How has telehealth and the technology that is needed to support it evolved?

We expected to see our telehealth usage fall off as COVID subsided, but we’ve actually had tremendous growth. We were incredibly fortunate, whether it was was luck or truly great foresight, that we had built an integrated telehealth solution a couple years before 2020. We have seen that usage has grown, primarily in behavioral health. But we’ve seen the integration between behavioral health and primary care and bringing those two specialties together.

There’s a very strong demand for integrated telehealth in that space and we expect that to continue. Your mental health is just as important as your physical health. Being able to match patients with the appropriate talk therapy provider anywhere in the country is incredibly valuable. We’ve seen that continue to grow. We haven’t seen the growth as much in some of the specialties or in primary care.

What are the benefits of a cloud-based system?

One of the biggest opportunities is in understanding data and large data consolidation, which can help predict outcomes for people. Our ability to leverage technology to improve patient outcomes is absolutely enhanced because people are on the cloud.

Some systems are more ASP based and not a true cloud. Some require  a thin client server download.

We’re incredibly grateful that AdvancedMD was architected for the cloud initially. You avoid some of those more technical components. You want a solution that you can access anywhere from any device at any time.

How much of your client base uses outside billing services?

In our client base, we have about 1,000 billers. They range in size from what we would call a bedroom biller serving one practice up to serving hundreds of practices.

Ultimately, it comes down to choice. Some people prefer to have total control and autonomy. They want to use software to do their own billing. They have expertise in coding, probably a medical coder on staff.

Some people want to leverage and use the capabilities of other people, so we have billing services. We actually have our own billing service, our own revenue cycle management team, where we offer that as well.

Then we have clients who just leverage our software. For us, about 30% of our total providers at AdvancedMD are using third-party billers.

How has consumerism affected medical practices?

There has definitely been a rise of retail and consumer-driven care. I can go to my local Walmart, Walgreens, or CVS and get care. We as healthcare IT leaders need to provide our physicians and providers with a frictionless experience so that they can provide a similar experience to their patients. As a healthcare IT provider, it’s our goal to equip our providers and our physicians with some of the same or similar tools and technologies so that patients will opt to see their primary care position instead of going to some of these other places. That could be things like the ability to schedule appointments online, have virtual visits, having mobile-friendly applications and portals to communicate with your provider, as well as real-time, fast communication.

How will AI change your business and your customers?

We’ve been working on an AI product suite for our clients. That would include things like improvements in documentation, where instead of spending an hour to two hours in the evening documenting and updating everyone’s patient charts, you could have it done with a couple of clicks.

Then you think about claims management processing , ensuring that the coding is correct and that you’ve included all of the right modifiers and everything is exactly where it needs to be. Leveraging AI in that is going to be incredibly helpful, too.

Internally for our business, we’ve uncovered multiple opportunities with AI in terms of our product, technology, release cycles, and how we QA the product to make sure that bugs don’t slip out. Using AI as a tool to help predict at-risk clients, figuring out where we need to have better communication, more transparency, and more connection with those clients.

In the right segments, AI will revolutionize this space. There’s always going to be a place for physicians, providers, nurses, MAs, and billers. But I believe that through AI, we will all be more efficient and will be able to focus on the things that are most important in our respective areas.

You’ve been at the same company for 19 years, intern to CEO, and most atypically to me, you’ve lived through several changes of ownership. What lessons have you learned?

The most important thing that I’ve learned is that people are the most important asset a business has. Starting as a company with 70 employees delivering service to 2,000 physicians and providers, to today, where we’re over 65,000 physicians and providers, doesn’t happen without incredibly talented people who are passionate and dedicated to what the organization is trying to accomplish.

Everything starts with the people. You have to take care of your people in the company. When you take care of your people, they’re more inclined to take care of your clients, and your clients provide for your shareholders.The financial results of the organization aren’t the objective, they’re the outcome.

By keeping that order of priority, AdvancedMD has been able to be more successful. I’ve been able to navigate throughout the organization for what has been a long tenure, but at the same time, it feels very short. I feel incredibly blessed to have worked and to continue to work with so many incredible people.

What factors will be most important to the company’s strategy over the next few years?

From a product and technology perspective, a few things. Simplifying our onboarding and service and introducing improved tools and resources for those who are learning the product. We will be enhancing our technology to reduce administrative time. We will be expanding interoperability and our healthcare connectivity. Delivering a best-in-class platform that ultimately helps independent positions and providers stay independent.

We’re excited about Francisco Partners. Like I said, it’s the second time that they invested in the business. We believe that they’re a tremendous private equity firm, especially in healthcare. I’m excited about the connections, the relationships, and the investment that they are enthusiastic to make in AdvancedMD.

HIStalk Interviews Najib Jai, MD, CEO, Conduce Health

Najib Jai, MD, MBA is co-founder and CEO of Conduce Health.

I trained as an MD, MBA but did not practice clinically and did not do a residency. Instead, I went directly to Oak Street Health. My entire career has been in value-based care. Conduce is focused on incorporating specialists into value-based care models through personalized referrals and contracting specialists under aligned value-based arrangements.

What does the primary care physician see when they refer a patient to a specialist?

It depends whether the PCP is in a hospital system versus an independent primary care organization.

At a high level, the way a referral typically works is that at the point of care, a primary care provider determines for a given patient that they need some sort of specialized care, whether it’s for their heart, their kidneys, or whatever that may be. After that is where there are a lot of heterogeneous workflows. The provider typically inputs into some system, whether that’s an EMR or some sort of separate referral management organization system, that the patient needs to see a specialist. Let’s call it a cardiologist. 

From that point, either the patient is given information to go out and schedule that appointment with the specialist directly, or there’s some sort of care team that’s affiliated with the hospital system or practice that makes that schedule available for the patient on the patient’s behalf.

From the specialist standpoint, their reception of that referral largely is the same. They receive some sort of electronic record that a patient has been referred to see them. Then either that specialty practice or the patient gets a visit scheduled.

Compensation is a question that comes up a lot when we think about value-based care for specialists. Part of what made value-based care work well for primary care providers was that, relatively speaking, they weren’t compensated particularly highly. This idea of being able to create additional financial incentives to boost their income was particularly attractive, and we saw the results of it. There were a lot of PCPs who were willing to participate in these models.

Your average specialist is making three to five times more than a primary care provider, so you have to think about it less purely from a financial dynamic and more through a matter of practicing clinical medicine. The average specialist isn’t necessarily interacting with patients  who are aligned with their specialty, which can be incredibly frustrating when you’ve spent 10-plus years of your life training to manage some of the more complex disease states that are out there.

Value-based arrangements enable these specialists to practice top of license to provide more comprehensive care to patients who need that specialist involvement in their clinical outcomes, which is a subjective or qualitative improvement in what they’re seeing where the more quantitative or financial dynamic may matter a little bit less.

Is the referring PCP notified when their patient has been scheduled to see the specialist, when their visit is completed, and what decisions were made?

They don’t know any of those things. Anything that happens out of a primary care office, particularly as it relates to specialty care, is a black box. You don’t know when the patient shows up. You don’t necessarily know what care was administered or what tests were taken.

For the primary care provider, you don’t necessarily know how to adjust your care plan for that patient. When the patient comes back to see you in two to three weeks, particularly if they’re a Medicare patient 65 and older with some sort of comorbidity, you’re relying on that patient to tell you what happened with their specialist, if they actually saw a specialist. 

In the most ideal outcome, they’ve got a great memory and maybe took notes, so they can essentially relay to that primary care provider everything that occurred. But more often than not, that doesn’t happen. Perhaps you don’t see the patient in three weeks, or perhaps it’s three months, and you really don’t understand whether or not that patient showed up with a specialist and what actually occurred in that visit.

That is part of the problem that we are solving. How do you make that black box a little bit more translucent so there is is more clinical co-management between these two integral providers for any given patient who needs to see both of them?  

Is technology the reason that patient information isn’t shared in what could be an urgent or critical handoff?

It still is a technology challenge. Every specialty practice looks dramatically different. Believe it or not, some groups are still dependent on paper charts even if they do have some sort of EMR. If you are the primary care group sending patients out, how you actually receive data and information can be incredibly strained. Whether you’re trying to get someone from the specialist office to return your phone call, or more likely than, not return a fax, it can be incredibly challenging.

The crux of the issue is just how heterogeneous every single specialist or specialty office is within a given geography within the United States. It’s largely a technological problem. Given the fact that a lot of these primary care offices are already strained with managing complex patients when we think about value-based care and Medicare populations, there isn’t a whole lot of time to make sure that that works out particularly well. 

From the specialist’s vantage point, there’s not a whole lot of incentive. Ultimately you can still manage and take care of your patients, absent of needing to take that additional step of going through all the complexity of reaching back out to that primary care provider.

But the one thing I’ll call out here, and maybe this is me putting on my clinician hat for a second, is that the stakeholder who suffers the most in that paradigm is the patient. Because ultimately, they’re having a series of disjointed clinical interactions, whether it be in a hospital system or a series of private practices, where no one is really speaking to one another. The patient isn’t well equipped to manage their care through that paradigm either.

Does the specialist expect or want to see the PCP’s information, or do they just assume that they will start from scratch, redo any tests or imaging, and trust the patient to tell them the rest?

Specialists would love to not have to rework every single patient they see from scratch. The cardiologist didn’t necessarily specialize in taking all the labs for a patient that relates to their electrolyte function for their kidney. They have no real interest in that, but when a patient comes without any sort of notes or information from the PCP, you’re starting from zero. That can be incredibly frustrating clinically. But again, there’s not a convenient or scalable way for that specialist to then go back to the primary care provider and obtain that type of data unless you’re in some sort of closed loop system.

As an example, hospital systems in some cases can do this particularly well because they’re all operating under a single EMR. Even if you can’t reach the primary care provider or the care team, you can go back to that EMR and evaluate what notes were taken and what images may have resulted. That streamlines your process as a specialist in theory, because they’re going through the pain of not knowing what is going on clinically with that patient when they arrive for their visit. You would think that would incentivize them to then go back after their visit with the patient and provide it to the PCP, but again, that connectivity isn’t there. Unfortunately, even if there were to be a desire to more clearly communicate with the primary care provider, there just isn’t a technological chassis in place to make that seamless. 

Anyone in the health tech space will tell you that it’s oftentimes less about the technology, less about how efficacious that technology is, and more about the workflow. How can you make this easier for any provider who is managing patients to use this tool or to manage this particular action?  Unfortunately, while there’s a lot of technology in some cases, there aren’t really a lot of great workflows that seem to embed well with what either a primary care provider or a specialist is doing to ensure more of that streamlined back and forth communication.

Isn’t doctors using patients as a data mule for potentially critical information a malpractice lawsuit waiting to happen?

It’s sad. It’s unfortunate. I go back to some of my clinical training on the south side of Chicago. There is a lot of onus on the patient to be this historian of everything that has happened to them. The more complex these patients get, the more history you have to keep track of. 

Most of the patients who are benefiting from value-based arrangements in Medicare don’t have great health literacy, so not only are we asking them to be historians, they’re not really equipped to do that particularly well. The result is meaningful delays in care or an absence of care that cause poor patient outcomes that are incredibly expensive, whether that’s a series of hospitalizations or the progression of a chronic disease to a point in which the morbidity and mortality rates rise meaningfully. We see that all the time in nephrology care.

That, unfortunately, is the current state. That is essentially what we’re trying to address, and more broadly, what value-based care is trying to address. How do we create the systems in place to prevent these types of outcomes? Discontinuous care is a big part of it.

How extensively are value-based care models being used that involve specialist referrals?

Value-based care is perhaps one of the more frustrating terms because it’s an umbrella term. It means a variety of different things. But most concisely, you’re essentially seeking to compensate certain doctors in these value-based care arrangements for the quality of care they provide versus the quantity of care they provide. That quantity dynamic is more akin to what we see in a fee-for-service paradigm.

To make it even more specific, what does that actually mean? How are you compensating quality? You put the financial responsibility on a single physician for the outcomes of their patient. If a patient gets hospitalized and it’s particularly costly, that actually impacts the financial well-being of the provider taking care of them, i.e., how much they get paid or not paid. 

Prototypically in value-based care, for the past 15 to 20 years that it’s been around in its various iterations, that financial responsibility has been largely weighted on primary care providers, which intuitively made a lot of sense. Primary care is one thing. Theoretically, every Medicare patient should have a primary care provider, but in reality, it introduces a challenging dynamic, which is that 75% of typical medical spend, for primarily Medicare patients, is weighted in specialty care. We’ve put a lot of financial responsibility on a consistent stakeholder in a given patient’s experience, the PCP. But that stakeholder doesn’t necessarily have the influence to materially improve or impact finances for some of these patients, and put differently, the clinical outcome for some of these patients. 

To go to the heart of your question of the implications of referrals, the moment you refer out to a specialist is not only that data and technological black box that I described before, but it introduces an unalignment when it comes to incentives. That initial primary care provider is highly incentivized when in value-based care to make sure that patient’s healthy, that they’re not being hospitalized, that they’re not costing a lot of money. That doesn’t mean an absence of care, because if you don’t do certain things, that also results in a hospitalization. It means in theory, trying to provide as holistic care as possible, inclusive of maybe wraparound services and nursing and whatever that might look like, particularly if you’re a hospital system and well equipped to do that.

But to that referred specialist, the specialist that a given patient was just sent to, it’s just being compensated for seeing that particular patient. Therefore, that specialist may very well do all of their typical tests. They might suggest a certain procedure. Let’s remove some of the presumed altruism in healthcare for a moment and think about it purely as a business. In that scenario, every single specialist should be incentivized to do as much as possible, because that’s how they’re going to be compensated particularly well. Now in reality, hopefully that doesn’t happen, but oftentimes it does. The implications of referrals and value-based care is that they typically are very expensive and not great for your bottom line historically in these types of models.

In the example of referring a patient to a cardiologist, the PCP would need to consider administrative factors, such as whether the specialist is taking new patients or whether the patient can get to their office. They would need to think about patient-specific factors, where one cardiologists might be preferred over another. Lastly, they have to think about cost and compensation under value-based care. What does that decision tree look like for the PCP?

I love that question and I’ll answer it in two ways.

The current state is that you are absolutely right in calling out that there are a lot of logistics that  should be considered whenever referral is made. First and foremost, who’s available to see this patient in the meaningful amount of time. In the cardiology example, the referral is probably for congestive heart failure, if we think about what’s most prevalent in the 65 and older Medicare population. That’s a meaningful chronic disease in which if you don’t see that cardiologist soon, you might be hospitalized. Availability is really critical.

Coverage in Medicare is important, but in some cases, it’s less of a consideration. It depends on some of the nuances, such as Medicare Advantage versus traditional Medicare, but a little less relevant versus a commercial population where you have to think about who’s in network or out of network, but it’s still a consideration.

Then to your point, perhaps the most critical point is the patient. There’s a presumption even in clinical medicine that every patient with a given disease, let’s say heart failure in this case, is more or less the same. But the reality is that that could not be further from the truth.

I had a really good mentor in medical school who always said that evidence-based medicine is informative, but inherently flawed, because it’s based on the average patient, and no patient is the average patient. It’s a foundation to make decisions upon, but it should not necessarily be used as true. 

Going back to your question, there are all of these different variables for a primary care provider to consider when making a referral, but keep in mind that the average primary care provider, even in a value-based arrangement where they’re incentivized to provide holistic comprehensive care, is still pressed for time. They have a variety of different patients. They’re trying to evaluate why this particular patient is there, what medications they have to make adjustments for, what additional appointments the patient needs to see them again. Of course, the patient isn’t just sitting there simply listening to the provider. They have things they want to talk about. Having spent time in clinical medicine, I can tell you that it’s a very focused encounter, but not often with a focused participant.

Saying all that to say that the reality is that when a referral gets made, oftentimes none of those factors are considered because there’s no time to consider them. To contrast that, how we think about it from a Conduce perspective is that we seek to embed ourselves in that workflow. Again, you can develop the best technology in the world, but if it’s not workflow friendly, it’s not going to matter to a given provider. We consider all of these particular elements based on our AI predictive model, and most importantly, understanding the patient.

When we think about what makes a good provider, we think about, is this doctor a good doctor or a bad doctor? That makes a whole lot of sense, but in clinical medicine, it comes down to the patient. We seek to understand patients first. We group them based on shared characteristics. Here are patients that have heart failure, diabetes, they live in this ZIP code, they lack transportation, and they predominantly speak Spanish.  Those patients are going to do well with a particular cardiologist and not so well with another cardiologist. If the cardiologist doesn’t speak Spanish, that patient population I described isn’t going to do particularly well with them.

Our first product, the Conduce Referral Engine, incorporates all of those factors — who’s available, who’s within a reasonable driving distance, and then most importantly, who’s going be a really good fit for this particular patient – and provides that recommendation to that primary care provider at the point of care. They don’t have to sit there and manage the 20 different things that are happening in a 10 to 15 minute encounter. Instead, they have a convenient list of providers directly in the EMR in a closed loop hospital system. It can be a printout. It’s whatever that PCP is accustomed to for a workflow to streamline that process and make the best personalized decision for that particular patient.

What are your priorities for the next few years?

What we’re building here at Conduce is these personalized referrals. We’re connecting specialists into value-based care models, but to put it slightly differently, we are ushering in an era of personalized healthcare, this idea that you can understand patients and their unique characteristics to inform where they will get the best medical care possible. Our models right now are about as bad as they’re ever going to be. I don’t think they’re bad, but we can continue to improve them with more data, more patients, and more clinical outcomes.

What the next one, two, or five years looks like for us is that we continue to interact and improve the lives of more and more patients, accumulate more and more data, and become that much more personalized in ensuring that we don’t just find the good doctors and the bad doctors, but we find the best doctors for a given set of patients. That’s personalized medicine. I honestly think that’s both the future of medicine and what value-based care is all about.

HIStalk Interviews Helen Waters, COO, Meditech

Helen Waters is EVP/COO of Meditech.

Tell me about yourself and the company.

I’ve been with Meditech for a number of years, having come up through the ranks in a variety of different positions.

Meditech as an organization has been in the electronic health record space for what’s coming upon 55 years, having in many respects given birth to the industry through the establishment of a programming language called MUMPS, which most people are familiar with. Our founder was the co-author of that language. Obviously we have since moved far beyond that language and into new technology and platform eras and have reinvented ourselves at several turns as the industry has changed.

How would you characterize the hospital EHR market?

It’s a market that has been busily on the move for the last probably 10 years. We’ve seen a significant amount of consolidation, which changed the market landscape quite drastically.

The rural and community healthcare space has been stressed by a lot of those changes. I was just reading this morning about the significant reduction of independent physicians in rural and community classified areas of the country being down to, I think the number was 12,000 or so. That has changed the hospital landscape accordingly as well.

But it’s an industry that is robust and tenacious. There are many places and spaces across the country, relative to rural and community hospitals, that are doing well to maintain their independence, to thrive, to recognize where and how new technologies can help them advance to more efficient organizations, more modernized organizations.

Conversely, we’re working hard to make sure that we can deliver advanced technologies and capabilities that allow them to do so, keeping our eye on the fiscal sustainability of the market as a whole. Most of us would acknowledge that in the broad landscape — whether they are large systems, academic systems, et cetera — there’s been a lot of fiscal strain on our industry from COVID and post-COVID.

We’re all working to try to advance into this new era, where innovation and technology can bear some assets that don’t always require people, or where technology can lighten and lessen the load. That includes the market space that we’re in.

When we talked last time, you mentioned that the high cost of implementing Epic or Oracle Health was probably locking in some health systems. Have you seen any indication that some of those health systems might, for financial or other reasons, now be open to making a replacement decision?

We’ve heard different levels of noise in that regard. I certainly think that the market has changed since you and I last spoke. The acquisition of Cerner by Oracle has changed the landscape in an interesting way. It was a rather large, significant investment on the part of Oracle. There’s going to be an expected return on that investment, which probably means a transition for a lot of customers. That transition will not be for free, I’m going to imagine. We see that market space attractively opening up to assess other alternatives. We are well positioned with Expanse to partake there.

The Epic customer base is coming up now on probably the 15- or 20-year mark. Our experience is that this is the point where people begin to think about their future. A lot of health systems bought electronic health records on the assumption that it would generate more volume. It would make them more fiscally successful. It would allow their expansion to grow and their quality scores to increase. Many of those same systems are struggling right now to figure out how to get to or out of red margins and try to get back to some fiscal strength and sustainability. 

That becomes more important now because of the advancements and the innovations that are going on in healthcare. There are important aspects to EHRs that are critical. They’re foundational digital systems of record. They are advanced. They are where people live and work all day long, doctors and nurses and allied health workers and many others that are in the health systems caring for patients. But they’re foundational. They are technologies now that have been in place for quite some time, for lots of different reasons.

We didn’t see the cost of these technologies come down, which for us was a bit surprising. Now those same organizations that may have overspent on the foundational technologies are feeling the challenge and the pinch of trying to find the funding to spend on the future technologies. That would relate to all aspects of artificial intelligence, ambient scribes, ambient chatbots, and certainly the large language models and generative AI. 

Our customers have been well positioned, both the smallest of them to the largest — which includes HCA and other larger organizations across the country — that are feeling well positioned for the investment they made in the foundational EHR, but now the position they stand in to take that to the next level of what the future of healthcare will be, which will be many aspects beyond the electronic health record.

What drives health systems to consolidate systems, which might mean choosing systems from an incumbent such as the EHR vendor that might otherwise not have been their first choice?

The consolidation factor has really surprised us. If you look at some of the larger national organizations, there’s very little patient crossover happening in those geographies when you own 80 or 120 hospitals. Otherwise, the technologies themselves have been ripped and replaced at times for not great gain. It depends on what system they were operating on. If it was a legacy older system, perhaps it made sense to bring into a more modernized platform.

Consolidation is something that everyone assumes or presumes to be the right thing to do, but I would say, generally speaking, if it’s not made in a wise, value-based mindset, it’s also proven to be a difficult, expensive proposition. We see a lot of the larger institutions looking to expand the footprint and spread the cost by extending systems into smaller facilities, and sometimes that ends up adding a burden of fiscal distress.

We’re big proponents of interoperability. We’re big proponents of moving that needle forward so that we can both consolidate data — which I think is more likely now to happen than ever in terms of how advanced some of the language models are, how advanced some of the analytics tools are — and then also able to interoperate with data to be able to share information across records, regardless of the vendor system source.

Interoperability has not been a technology problem in a while, but the industry has forced itself to make it a technology problem. But I think we are dawning a new era where the ability to have to consolidate on a single system may not be as prevalent as it might have seemed to be. If you look at the data from the major quality reporting systems. we haven’t achieved the scale that promised better efficiency, better quality care, lower cost, and higher patient and family satisfaction. If you don’t have those factors and you have increased your operating expense spend on foundational tools, you can be in a really challenged space. 

We are obviously proponents of interoperability and of the requirement for the vendor community to share information and data so that organizations can make sound decisions, but don’t all have to be on a ubiquitous platform.

Software being “in the cloud” doesn’t necessarily mean the same thing to every major vendor. How would you summarize cloud use and how will it develop further?

Cloud maturity has exponentially grown since we last talked. It has for our company. It has across the industry.

You’ll see organizations that are more progressive developing cloud-native applications, which we’ve done a series of, to ensure that the electronic health record is, in architecture and not just in front end, highly modernized. Most of the vendors in different capacities are moving in that direction, to different degrees.

Some are lifting and shifting an on-prem system into a cloud, but not necessarily taking advantage of that cloud architecture. It might just be hosted there. You might not have anything natively developed for the cloud. You might not be offering a SaaS model.

We transitioned both the development of new applications to be done natively in the cloud to modernize tool sets as to how we develop those applications, and in addition to that, we are obviously operating fully in the cloud and offering a service solution. This is quite different and has proved to be a really good decision for us. We announced in 2018 and began in 2019 and 2020 to see that uptick in the market. Now we have well over 120 customers that are operating natively on our cloud services offering called Meditech as a Service.

What results have you seen from working with Google and what projects do you have planned?

The product that we announced at HIMSS22 we called Expanse Navigator, which is a search and summarization capability within our record. It’s the ability to take advanced search features within the EHR and access and synthesize and surface structure and unstructured data. You have all of those aspects of scanned docs, handwritten notes, and images that are surfaced and scanned both within the live system and then obviously from legacy systems.

One of the advantages we saw there was being able to truly know the patient for whatever term they’ve been with that health system. Oftentimes as people migrate and move EHRs, a lot of the data gets left behind. This allowed us to bridge those two worlds for our customers and for any customer coming off of a legacy platform.

This initial product was built off of the BERT language model. It wasn’t necessarily generative AI, but it was one of their first large language models. The feature in that was called Conditions Explorer, and that functionality was really a leap forward. It was intelligently organizing the patient information directly from within the chart, and as the physician was working in the chart workflow, offering both a longitudinal view of the patient’s health by specific conditions and categorizing that information in a manner that clinicians could quickly access relevant information to particular health issues, correlated information, making it more efficient in informed decision making.

We felt that was a big step forward to give physicians who are quite busy in their 10 minutes with the patient wanting to feel more confident in what they were doing, making sure they had the right information in front of them.  It’s been really successful. It’s highly valued and enjoyed by our customer base, Expanse Navigator.

Beyond that, with the Vertex AI platform and certainly multiple iterations of Gemini, we’ve walked forward to offer additional AI offerings in the category of gen AI, and that includes both a physician hospital course-of-stay narrative at the end of a patient’s time in the hospital to be discharged. We actually generate the course-of-stay, which has been usually beneficial for docs to not have to start to build that on their own.

We also do the same for nurses as they switch shifts. We give a nurse shift summary, which basically categorizes the relevant information from the previous shift and saves them quite a bit of time. We are using the Vertex AI platform to do that. And in addition to everyone else under the sun, we have obviously delivered and brought live ambient scribe capabilities with AI platforms from a multitude of vendors, which has been successful for the company as well.

The concept of Google and the partnership remains strong. The results are clear with the vision that we had for Expanse Navigator. The progress continues around the LLMs, and what we’re seeing is great promise for the future of these technologies helping with administrative burdens and tasks, but also continued informed capacities to have clinicians feel strong and confident in the decisions they’re making.  

The voice capabilities in the concept of agentic AI will clearly go far beyond ambient scribing, which is both exciting and ironic when you think about how the industry started with a pen way back when, we took them to keyboards, and then we took them to mobile devices, where they could tap and swipe with tablets and phones. Now we’re right back to voice, which I think will be pleasing provided it works efficiently and effectively for clinicians.

What benefits have clients seen from Traverse Exchange?

We launched Traverse Exchange in Q4 2024. We had actually started the year prior in Canada. It’s a data exchange between Meditech customer organizations and organizations on other vendor EHRs. The core tenet is to share patient data regardless of where the patient is receiving the care and regardless of the EHR they’re using. It allows the customer to remain on or implement the systems that work best for their organizations.

There’s burden reduction in that we’re sharing information into and accessible within the standard clinical workflow and  to move beyond cumbersome static documents, which we’ve been dealing with with CCDs and even cumbersome data exchanges like CCDA. It’s leveraging our FHIR-based requests for targeted data at the point of care and physicians being able to easily access information regardless of its origin. We talked to so many customers who will say, I don’t want to go to XYZ vendor. I don’t want to be offered a connect system. But I’m terrified of being left out and I’m terrified of not having the right amount of data for my patients. 

The sole reason we did this was to try to finally debunk in the industry the fact that everyone has to be on the same system to arrive good decision making and get quality outcomes. We are pushing this envelope significantly. We’re going to push it on our EHR competitive partners and ask this industry to come together to finally allow for the free and easy exchange of information directly into clinical workflow. We’re happy to participate, in turn, on the other side.

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

I would say the same factors that have been in the past years. Continued introspection about the things that we do really well and the aspects of our company that we need to continue to retool for the future and the market that we’re in, actually the market that is in front of us where the puck is actually headed. Continuing to deliver very effectively for customers and be sure that our customers can do the speaking on our behalf.

Leveraging the success of HCA, who is rolling out our Expanse platform. That was a calculated decision. It was a value-based purchase on their part. We intend to prove the value relative to the outcomes, the clinician satisfaction, and also the innovation factor, which we are both seeking in this partnership. By the way, not just HCA. I would say that you’ll see us continue to focus on our outcomes in other markets where we have a good foothold on potentially driving and leading the market.

The US market consolidation was outside of our control, and there were some real benefits to that for some vendors. We intend to challenge and continue to move forward passionately the way we always have, but making sure that we’re continuing to adjust for what the market is looking for.

HIStalk Interviews Andrew Smith, Managing Partner, Impact Advisors

Andrew “Andy” Smith is founder and managing partner of Impact Advisors.

Tell me about yourself and the company.

I started Impact Advisors 18 years ago with my brother, my wife, and one of our dear friends. It has been a journey. I feel very blessed and grateful for all of the great clients that we get to work with and all the great associates that have joined our team.

We are dedicated to healthcare. We have become a full-service healthcare management consultancy over the last 18 years. I am  proud of the work we’ve done.

What topics are top of mind for health system IT leaders?

It’s no surprise that merger and acquisition activity is driving a lot of work, particularly in the technology space. The technology becomes the central nervous system of a health system. As you merge, acquire, and increasingly, divest, we’re seeing a lot of investment to standardized systems. 

That ultimately drives standardization of systems, workflows, and process. That’s the biggest driver of technology change, and in itself, drives a lot of other things in terms of change management, optimization around clinical or rev cycle, labor force, or supply chain. We have built a lot of services to complement the technology change. We consider ourselves a technology-enabled process improvement firm. That’s an important part of catalyzing change and making sure that it’s persistent.

How does cloud migration fit into the strategy of health systems?

The migration to the cloud is probably going slower than most people would anticipate. But it’s obviously important in terms of scalability, the ability to make change quickly and to do it economically. It’s definitely a direction that’s going to continue. We have built services to help our clients make that journey. We think it’s an important complementary technology to all the other things that we talked about in terms of standardization, normalization, and change management.

What is the level of demand for AI-related services?

The demand is high. I don’t know if we’re at the zenith of the hype curve, but we’re probably getting pretty close. It’s getting debated in boardrooms. People are concerned about it. Our particular perspective is that the promise of it is unparalleled. This is a real revolution in technology and the opportunity is amazing.

It has been a slow uptake. A lot of people are hoping that their core vendor platforms are going to help them with this. But we think it’s a much more nuanced kind of patchwork quilt that people are going to have to embed into all of their systems.

Our advice is, don’t take it all on at once. Find a particular area or use case and focus on that. It’s hard not to get excited about it, but we will have to go through that hype curve. Then it becomes useful and embedded in the technology and workflow.

AI is changing daily and switching costs seem to be generally low. How will vendors plan for possible churn?

Our advice is on these innovative things is, don’t bet the farm. Place bets that you may be OK with displacing in two or three years as the market evolves, where it’s really nascent where we are right now. There will be a lot of change, a lot of dynamicism. It’s important to pilot. It’s important to be able to move quickly if you recognize that things aren’t working and cut bait and move on.

How are health systems addressing clinician burnout?

Just cleaning up the AI-generated note, abstracting, and patient communications are all good use cases for AI. All would help with clinician burnout. There’s high promise there. If you look at some of the EMR technology, what they’re doing in terms of building the note and building frameworks and templates for clinicians is probably one of the best things we can do with AI.

As they say, AI isn’t going to replace our clinicians, but clinicians who don’t use AI might get replaced by clinicians who do use AI. That’s really the future. This is not going to replace our clinicians. It’s got the promise to make their lives easier, to improve their efficacy, and to improve the clinical outcomes as a tool, but not as a displacement technology.

How do AI vendors pick a path to coexist with the handful of major health system EHR vendors?

There’s such a high barrier to entry. The path would be to find an area of expertise that’s maybe complementary or a different business model, like in the ERP space, where cloud vendors remove some of that high cost barrier to entry. 

We’ve condensed options in the EMR space to just a few platforms, and that won’t change any time soon. It takes years and it’s a complicated workflow that is hard for a new entrant. The technologies that I get excited about are those that are tackling or complementing a particular use case. Some exciting things are happening in the ambient documentation space, but it’s a high barrier to entry.

How do consulting companies resist the urge to offer any services that someone will pay for and instead develop a narrower but deeper and more easily explained expertise?

We develop services in collaboration with our clients. We’ve got a really nice relationship with them, I am grateful and thankful for the clients that we get to serve. Our service lines are developed collaboratively where our clients have need.

A CEO told me that no matter what the market is, if you’re helping people be more efficient, be more safe, and provide better clinical outcomes at a better price, you’re always going to be successful as a health system. If we can support that mission, then we’ll always be successful as a consulting firm. 

We’re excited about data and AI as an important growth topic for us. Business process outsourcing is a huge growth area. As people reach steady state and have implemented new ERP and EMR platforms, how they can maintain and enhance those platforms at a cheaper price? That’s a huge growth area for us.

We’ve developed some near-shore capability. We’ve developed a lot of outsourcing capability. That’s a real growth engine for us. As I said, mergers and acquisitions are driving a lot of it. If we can help our clients get to whatever their new normal is, or their aspirational state post-merger, that’s important and something that our clients are going to demand.

What is the health system balance now among outsourcing, managed services, and contracted short-term resources versus building their own internal expertise?

I’ve seen growth in demand around discrete outsourcing around particular processes, particularly AR management, rev cycle, supply chain, and clinical help desk. Things that are discrete carve-outs that may not be the mission of a health system. Economies of scale can be provided if you outsource some of those things, and maybe a discipline and set of methodologies that might be helpful.

We’ve seen a return to full outsourcing over the last couple years, but I’m not sure that’s always as effective. Sometimes the health system needs to control those moments of truth — their interaction with their customers, their clients, and their caregivers.

What is the status of remote work?

It has been fascinating to see how quickly that changed with COVID. We have always been remote. We have two offices, both in the Chicagoland area, but we are working in 48 states right now and have people living in all 50 states.

It has been an interesting shift for our clients as they move to remote. It requires a different management model and a different level of discipline and  communications to make that effective. Some of our clients have struggled with it, and some are really excelling at it.

I don’t see that it’s ever going to go back to the expectation that everybody will be in the office five days a week. Our clients like some flexibility, their staff likes some flexibility, and our staff likes the flexibility. It hasn’t reduced the efficiency of our clients or certainly our business, but you do lose some things around communication, teamwork, and joint problem solving. A hybrid environment makes a lot of sense.

We were wondering if this would be threatening to a consulting model, that all of a sudden our clients, instead of hiring consultants or purchasing services, they would just hire people in Fargo, California, New York, or wherever the talent may be. That has happened a little bit, but for the most part, we haven’t seen a huge displacement of our services resulting from that.

How are health systems and your company reacting to recent economic events, the possibility of major HHS changes, and the unknown role that the federal government wants to take in overseeing health systems?

I’ve talked to a lot of our clients and they are all worried about it. It’s at the top of everybody’s list. They are worried about cuts to Medicare, and Medicaid. 

NIH cuts have already affected them. I met with a researcher at a children’s hospital a couple of weeks ago whose entire budget had been slashed. They had longitudinal studies in flight and they are scrambling to find private and other public funding sources. Hospitals and providers will have to make some pretty difficult choices about whether they continue to fund these through operating income or they close down and scuttle some of these programs. 

They are all threatened and not quite sure what exactly it means, but I see our clients starting to tighten the belt, start some austerity, and get nervous about these anticipated changes.

It’s a tumultuous time for our providers and our health system right now. I feel an obligation to help find a way out of this, to find creative solutions. The answer is almost always that you can do things more efficiently. If you can do them more effectively, if you can make things safer and improve outcomes, that’s good for everybody. That’s what we’re going to stay focused on.

We talk about rising tide and waning tide services. Rising tide services might be as health systems can make big investments in big technology platforms, that’s a rising tide. We can help them with that. If there is waning tide, austerity, or labor issues, we have a set of services to help with that, too, in terms of labor optimization, change management, and workflow optimization. We can do that in different ways, such as that we would only benefit if they benefit. We can price things differently and more creatively. We can help our clients navigate these tumultuous times, but it’s going to be weird for a bit and our clients are nervous about it.

Despite some of the challenges, I’m really excited about the promise and potential of the solutions, the creativity, the technology, and the change. It seems like we’re working through a really magical time in our industry. We’ve seen a lot of change. I’ve been in this industry for 30 years and I’ve never been more excited about the pace of change, the opportunity, and the new and novel things that we’re doing as an industry. It’s an exciting time. I’m pleased to be serving our clients in the industry and I’m proud of our team that we’ve built and the work that we are doing.

HIStalk Interviews Justin Dearborn, CEO, Praia Health

Justin Dearborn is founder and CEO of Praia Health.

Tell me about yourself and the company.

Praia Health is celebrating our one-year anniversary of our spinout of the Providence health system and their incubation group. We are carving out a new space around consumer orchestration within health systems. Our primary customer is a health system that wants to improve their patient- and consumer-facing experiences, whether it be an app, web, or call center. We help with orchestrating all the touchpoints and coordinating those. It looks similar to how most consumers are used to interacting on the internet, being very personalized and removing friction where we can. It’s a new space of consumer orchestration.

Prior to coming to Praia, I was the CEO of another patient engagement company called Patient Bond that is now a part of Health Catalyst. Before that, I spent eight years at Merge Healthcare as CEO. They’re a publicly-traded medical imaging company that was acquired by IBM.

How much attention are health systems paying to the digital consumer experience compared to other industries?

There is interest and discussions. A lot is going on at the macro level that has maybe defocused some of those projects, but we’re still definitely in the early adopter phase of the market. Always good conversations with the chief strategy, chief digital, or chief transformational officer. Most of the meetings are very receptive.

There’s a lot that sometimes needs to happen on the back end to allow for a very elegant front-end experience. There’s some organizational change, some change management that is probably responsible for longer sales cycles, but we see receptivity to the message and everyone gets it and nods their head. We want a better consumer-patient experience. We want it to mirror Amazon, which is a tried and true analogy that everyone uses it because it’s a good analogy and it works.

It’s hard to say you wouldn’t want to deliver for your patients a very personalized experience at scale. If you and I were both using the Providence app, for instance, we could each open up our apps and we would have a different set of calls to action and information based on what they know that we want to see and don’t want to see. It expedites that and keeps you engaged. I don’t recall ever hearing, “I’m not interested, it doesn’t make sense.” It’s more about, do we have budget this year? Do we have resources? Is it on the roadmap? And now we’re going to try to figure out what’s going to happen with Medicaid and how that impacts our system. That’s not unique to Praia, of course, but just a little bit of distraction to start 2025.

How do you approach the return on investment questions?

This could fall into marketing, and not that those projects don’t need a tangible ROI, but absolutely, this is an ROI sale. We approach it that way. If something’s already been approved in a new project, a new website design, we could fold into that and enhance that. But overall, it is an ROI sale. We have incredible data from Providence that  we released a few months ago that shows a really compelling ROI. The ROI tool we use can scale up and down. Every system is not going to have the scale of Providence, but the same levers are in place across the board.

We’re very bullish on the ROI. We’ll actually contract around that, do some gain share and take some risks because we’re confident in the return. We definitely approach every opportunity or engagement that it has to have an ROI to get to the starting block.

What lessons have been learned from big companies in healthcare, such as chain drug stores or insurers, that could be applied to a health system?

We think it’s across verticals. It’s just loyalty and driving engagement. It’s been proven by some great research that’s out there that nudges within an app work. You have to be cognizant not to over message, which some industries have been guilty of, but keeping a patient or consumer engaged.

One of the theses for Providence, where this was designed five years ago, was that they were seeing only about 1.7 visits a year per adult, and the average adult has five different interactions with the health system. They found that most health systems don’t have compelling reasons for you to go back and visit the health system in between episodes of care. They can deliver up content that’s relevant to you. Every health system has a plethora of health and wellness data, but how does it get served up to you? How do you know about it? It could even  be spiritual in Providence’s case. They have a great library of material and they know who want to engage with that and who won’t.

It’s really just serving up content and making it relevant for you. When you have a health and wellness concern, go to the Providence app first, there might be something there for you even if they don’t deliver the service. They might have a network of providers. It could be physical therapy, it could be through a medicine partner. They can deliver you into that experience through the Providence app in a frictionless way. You don’t have to create another ID, log in, or manage 18 or 20 different apps. It can all be delivered within the Providence app, even if it’s not a Providence service, per se.

Do consumers feel aligned with a health system that is attempting to market to them or engage them between encounters with what might feel like a sales pitch?

There’s definitely that risk. But great data suggests that patients trust their health system, whether it be big brands like Cleveland Clinic, Mayo, and Providence. Maybe to the same extent, for independent pharmacists. Depending on where you live, there still are some independent pharmacies where you get to know your pharmacist and have a trusting relationship .

But otherwise, the research would suggest that people do want to get content a from a health system. I think that’s well earned. Over half of the health systems are non-profits and a lot of them are faith-based, so they are mission driven. They have to run businesses, but they really do have the patient’s benefit in mind. You can draw comparisons to some that are purely profit-driven and you could tell the difference in experience.  I think they are a trusted source.

Some maybe have been a little bit complacent with that status, and they are getting channeled into some new business models. One Medical is a great example. They do a great job, but they are forcing some systems to start moving and focusing on digital, because One Medical is a great digital experience. It’s only going to get better with Amazon owning them. That’s creating some pressure, and that’s sometimes what is needed to force some innovation. But health systems are trusted sources in the community, and they are more and more starting to leverage that.

A business would target those consumers who have the potential to be the most profitable. Do health systems look at providing services such as population health or do they focus on selling profitable services?

I’m sure that goes on. I would say that a lot of the non-profits we’re working with do focus on top of funnel. Once they are in this system, so to speak, and they’re a digital user, they will  interact with them around knowing that a care gap is coming up. I haven’t seen, “Let’s go target this audience because we need to fill up the ortho schedule for knee replacements,” but they will absolutely do a great job with tools like Praia targeting, “ You’re overdue for your colonoscopy” or “you’re overdue for your mammography exam.”

The click-throughs and actions are taken when it’s delivered through an app, and Providence has allowed us to publish on this, it’s three and four acts of a text message and email, et cetera. Phone calls are great as well, but they don’t scale as well, of course, and most people don’t answer their phone. It’s more targeted around care gap closures, I will say that some more nimble systems, if they know that they’re having a couple of open days, will reach out to folks that in the past who needs a knee replacement but didn’t schedule for whatever reason. Maybe nudging those along. There’s some incentive to do it because there’s going to be some openings in the schedule. But what we see predominantly is more around care gap closures. There’s enough of that to keep them busy.

What are the challenges in communicating with people who prefer texting or emailing to a phone call or vice versa?

You would naturally think that it’s going to be age driven, but we’re definitely seeing that it’s not. My grandmother was 92 and she was texting her clinician. It’s going to be more pronounced as everyone ages into it and has grown up texting and using email and app communications. It’s definitely a split.

AI comes up in every conversation, so every health system is analyzing how to use it, more on the back office side and the first line of interaction. But because it’s healthcare and it’s personal, a good mix should be available. There are people that want to talk to an empathetic caregiver and somebody who’s going to actually walk them through something and hold their hand, so to speak, over the phone. But they are more routine communication for sure.

Providence has another product they built internally around email. They analyzed the number of emails that their physicians get and it can be hours a day of cleaning out your inbox. They found is 80% were more routine and could be handled by a front office person or a password reset or something like that. Trying to make the clinicians more efficient, because they all recognize — especially the faith-based and non-profits — this is personal. Most people, when it comes down to something life threatening, want to talk to a human being.

What other data sources outside the EHR might be useful for a health system that is trying to address consumers rather than just episodic patients?

That is the key selling attribute of Praia. We leverage all the great work that the EHRs do. We see MyChart and they do a great job, but it’s really designed and focused on the clinical interaction. Even some of that could be done a little.

In a Praia experience, and I’ll use Epic again, MyChart will be will show up. At every screen, you can punch out and click through to MyChart if you want to look at your lab work. Depending on the system and the health system, you could schedule through Epic, but there’s a lot of other scheduling applications as well. We definitely leverage that and enhance the value, because more digital users in a system are better for the health system, better for the EHR, better for us. We absolutely drive adoption there.

Rock Health did a great paper on this last year. About 80% of health and wellness happens outside the clinical visit. How do you get into more of that? We have a couple of partners on the Praia platform, Foodsmart being one of more food is medicine. That’s a very rightfully popular area right now. That’s a separate company. But Providence has a relationship and we can serve that up in the Praia app, make it seamless for a consumer-patient within Providence app to leverage that. There are other companies like Rosarium, where if you’re qualified from your insurance or Medicaid and will be using a wheelchair for six months, they will build a ramp and make it accessible in other areas. The ecosystem of partners is unlimited, but that’s outside the clinical interaction. Providence and forward-thinking systems want to be a part of that and keep you engaged with them to make your life easier with just one application.

Amazon is using AI in its health assistant to push specific products based on a user’s profile and their use of its website. Could AI be misused in an attempt to personalize the healthcare consumer experience?

The systems we’ve interacted with are very cognizant of overreaching there. Providence, for example, has a governance committee. They are focused on AI  in the background. Administratively looking at whether the bill’s coded correctly. Can we answer some of these questions around like password reset, or what’s my insurance deductible? They use AI for that, but as far as interacting, anything touching clinical, anything that could be seen as practicing medicine, systems haven’t, for the most part, taken that leap. I think they are conscious of what you just said.

Another example is Abridge. It has been in the news a lot and they’ve done a great job with ambient listening, which is making the physicians more efficient. Most systems and patients are comfortable with things like that. They do a lot of voice of customer, voice of patients research around this and  are comfortable. Does anyone want to interact directly with an AI bot yet? Not for clinical. Where’s my bill, or I have a question about it, maybe. They are being methodical about how AI interacts.

On the Praia side, our platform can ingest any AI agent or application that a system has built and deliver that. But we’re also taking a very measured approach around that. Hype is probably unprecedented, but there’s not a lot of tangible ROI yet. Every health system is experimenting and piloting, but there’s not a ton of great use cases outside of the couple that I mentioned.

What factors will be most important to the company over the next couple of years?

More customer input, and customer being the health system. This was built at Providence. It was intended to be commercially facing me, not solving a Providence-only problem. We just need more data points, more customers on the platform.

Unfortunately for first half of the year, a lot of systems have been reluctant for systems to move forward, which is not just a Praia concern. With the potential cuts in Medicaid, and other grants have been cut, we’ve been interacting with a lot of systems and we’re pretty far down the road. Then budgets have been frozen because of the some of the NIH grants that roll downhill.

But I think there will be a tipping point where a couple of big, notoriously skeptical, hard-to-hard-to-get-on-board health systems will come on board with Praia. Then it will be like what happens with a lot of startups, where the momentum will move fast from there. But really, it’s it’s around knocking down those next group of health systems so we can continue to increase the the R&D spend and get additional perspectives on what will be helpful.

What we’ve found so far is that once the platform is in place, a lot of use cases come up. We’re trying to be careful to only bring to market use cases that have applicability across every health system. Like it can be vaccine scheduling with Walgreens, or we announced a partnership and investment from Labcorp streamlining the way lab ordering works from the physician pen, so to speak, to the patient and making sure they show up knowing what’s expected of them so they show up at the right facility at the right time and have done the right preparation in advance. Things like that will continue drive use cases and, frankly, value from the platform. But really, for us, the focus is just onboarding more customers in 2025 so we can continue to build that knowledge base.

HIStalk Interviews Sriram Devarakonda, CTO, Cardamom Health

Sriram Devarakonda, MSEE is CTO of Cardamon Health.

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

HIStalk Interviews Ed Gaudet, CEO, Censinet

Ed Gaudet is founder and CEO of Censinet.

Tell me about yourself and the company.

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

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

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

Does that risk change with cloud adoption?

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

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

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

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

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

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

How are health systems collaborating to share their cyberattack experiences?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

HIStalk Interviews Stuart McLean, CEO, Nordic Global

Stuart McLean, MBA is CEO of Nordic Global.

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Will the shift from onsite consulting to remote services last?

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

Will AI change your business?

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

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

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

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

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

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

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

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

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

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

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

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

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

HIStalk Interviews Jason Rose, CEO, Clearsense

Jason Rose is CEO of Clearsense.

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Does AI create new business opportunity?

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

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

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

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

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

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

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

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

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

How has the health tech business climate changed in Nashville?

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

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

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

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

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

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

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

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

HIStalk Interviews Erine Gray, CEO, Findhelp

Erine Gray, MPA is founder and CEO of Findhelp. 

Tell me about yourself and the company

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

HIStalk Interviews Frank Harvey, CEO, Surescripts

Frank Harvey, RPh, MBA is CEO of Surescripts.

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What are complementary areas that you might consider?

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

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

What does the health tech investment climate look like?

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

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

What are your priorities over the next few years?

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

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

HIStalk Interviews Bob Katter, President, First Databank

Bob Katter, MBA is president of First Databank.

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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