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HIStalk Interviews Gabriel Orthous, CIO, Central Georgia Health Network

June 12, 2019 Interviews No Comments

Gabe Orthous is CIO of Central Georgia Health Network in Macon, GA.

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Tell me about yourself and your job.

I’ve been in the business for 20 years. I started my career in revenue cycle, moved on to analytics and population health, and now we’re in the throes of value-based care and providing an understanding around the risk-based models that payers and CMS are presenting. Being accountable and at the forefront of provider engagement.

We support 1,100 providers in our network. Every single modality aligns with Navicent Health, which is our major hospital in this area of Macon. It’s a large footprint of the providers that we support from a PHO perspective.

My background is a technologist. I’ve been an expert apprentice of population health and value-based care. I also teach population health at a couple of colleges as an adjunct professor. I’ve been at this game for about five to six years, seeing the transformation from a quality-based PQRS kind of perspective into, how do we make these things actionable? How do we quantify the effectiveness of these programs to lower total cost of care? Because at the end of the day, that’s what we’re trying to do.

How do you see a clinically integrated network changing the relationship between independent physicians and hospitals?

I’ve worked as a consultant with several types of CINs, many different flavors of those. The relationship between a hospital and the community physicians varies throughout the United States. For us, we’ve always had a strong relationship with our hospital system, being more on a regional level.

It depends on the market. If you come from an educational hospital or a medical center that’s inside of the perimeter here in Atlanta, for example, it’s a little bit different on how they deal with their independent providers. There’s a lot more competition. We’ve been able to build that relationship. It is a bit of relationship building, understanding the priorities of those physicians and enabling them to do the things they need to do to make the hospital successful and vice versa.

Is the trend of hospitals acquiring practices changing the dynamic between independent doctors and hospitals?

I’ve seen in the past 10 years the ebbs and flows of that strategy of going after physician practices and becoming employed versus affiliated. Again, it depends on the health system. You have a “who moved my cheese” ideology of some of the physicians who are now employed, because now they have an 8-5 job or now they have a set of requirements or standards being imposed by their employer, which is in this case the hospital. For them, there’s not that risk of having to pay the light bill at the end of the month. It lowers the risk for those providers to go work for the hospital.

At the same time, the hospital now acquires that risk, and acquires the risk of making sure that the productivity — and in our old fee-for-service world, the RVUs – stay up. But now that dynamic is also changing, because now you have quality measures, specific programs that are requiring these physicians to do certain things in closing care gaps, HEDIS, etc. that now the hospital needs to be able to influence.

It is a hard proposition. These providers are already employed by the hospital, and having some providers do what they need to do to close the care gap, for example, when they may not see an immediate benefit in that performance. But as a whole system, you would.

The idea of affiliation is important to understand. Inside the walls of the hospital, you can enact certain change. You have one view of the world through your EMR, whether it’s Epic or Cerner or any type of hospital-based system. But when you get out into the community, you see more of a diversity of EMRs. It’s harder to enact change when things work differently from a workflow perspective. Epic-everywhere or Cerner-everywhere types of environments are few and far between. At the point of care, it’s important to have an understanding of the topology of that network and become the network of truth as opposed to a single source of truth.

What technologies are important when first moving toward value-based care?

One of the most detrimental phrases in today’s healthcare space is saying, “I don’t know what I don’t know.” Unfortunately, many organizations that I’ve worked with are always saying that. There are different views of the world of how you look at your data, how you look at analytics. One is the clinical focus, the EMR perspective of workflow and patient-centered focused around clinical things that have to occur. Usually those are part of a system of trying to identify CPT codes or ICD codes in order to get paid through a billing RCM model. You have dichotomies of political and revenue cycle. That’s just one component.

On the other side of the house, you have the payer view of the world, which is adjudicated claims that come with a three- to six-month lag of information, telling the providers, “You forgot to do an A1c” or maybe asking the provider to provide a supplemental data set to close the care gap.

The way I look at value-based care today, and to prepare for a technology stack that’s able to be nimble, is to have partners. If you have the money to create your own, that’s great. But have partners that are going to be nimble enough, that are going to be helping you through that data journey and that have flexibility in advocating that data and making it be purposeful.

A lot of times we get into these projects or these technology implementations that are more of a Connectathon. Just send me all the data. Being purposeful, starting with the low-hanging fruit, showing value initially, success factors, identifying the right KPIs, and then building upon that.

So I would say, one, nimble. Two, a technology stack that can aggregate data from disparate sources, including social determinants, care management, and all the other data sources that are out there. Of course claims and of course clinical. Then number three is letting you look at the view of the world through those different lenses. Just clinical, just clinical plus RCM, clinical plus RCM plus post-adjudicated, social determinants, That’s when you start identifying the right populations and how to target things that are going to be part of your performance contracts.

Will being exposed to those technologies encourage practices that are less technically savvy to consider the possibilities of using other technologies to enhance their practices?

Absolutely. You’re bringing up a great point, which is point-of-care analytics and using technology and data to enhance workflows, patient experience, and the things that you just mentioned. But there’s also another component, which is the network view of the world. What are the things that are going to get these physicians the most money for their risk contract? What are the things that they need to do at the network level to have a critical path for patients to follow so that they have better quality and lower cost of care?

Those are two separate things. One is more episodic, while the other is more longitudinal. The technologies and the data required are a little bit different, although they come from the same sources.

At the point of care at the physician level, having additional data sets that are external to “patient presents” is important. I’m going through an HIE implementation right now with a local HIE here in Georgia. I truly understand the physicians wanting to see what happens outside their doors. When the patient presents to the ED, they want to see those discharge notes. That’s an important factor. The problem with interoperability and intraoperability is that those files become convoluted quickly. A CCD as it stands today is a bulky file. It’s hard to read and it’s hard to realize what’s important and what’s not important in there. So we lose a little bit of the usability factor in the technology utilization that we have today.

There are many new technologies that are coming about that are helping the providers focus on what’s important for the patient that presents in front of them from that external actor. But unfortunately, we’re not there yet with all of these EMRs. I’m not talking about one EMR or another. All of them have a lot of work to do around interoperability and parsing the right data set for the right patient at the right time.

What frustrates most people about interoperability isn’t practices not sharing information with each other, it’s that hospitals and practices don’t share information. How do your members see that situation?

It’s a challenge of not knowing what happens outside your doors, whether it’s the walls of a hospital or the doors of the physician’s office. More information is the best around medication adherence, for example. It would be awesome to understand what types of medications are being prescribed outside of that one encounter that you have with your patient.

It’s easier on the commercial side of the house with payers because it’s different types of populations. But when you get into Medicare, ACO, or frailty, for example … frail patients who come in may be prescribed seven medications in seven points of care. It is a struggle and a challenge for providers to understand the full totality and the picture of these patients.

From a workflow perspective, having only 15 minutes to spend with a patient diminishes the amount of value add. A lot of these providers don’t have access to the data. Not just the data, but having enough time to be able to have a conversation with the patient and have that relationship being built.

We still have a lot of problems getting external data into the point of care where it can pinpoint the providers to do the right thing with the data that they’re seeing in front of them that is actionable. It’s kind of a buzzword these days that everything has to be actionable, but it is the truth. These EMRs are becoming more and more convoluted, built on top of version, on top of version, on top of version, and not necessarily making it easier for the provider as opposed to death by a thousand clicks.

Are practices maximizing the value of that 15-minute visit by collecting more information from the patient beforehand and then following up with them electronically afterward?

There’s definitely an art and a science in that gathering of data pre-visit and post-visit. It really depends on the engagement level of each individual patient. We can have predictive models as to which patients are more likely to fill out a survey pre and post. But in general, I’ve seen minimal impact and engagement from that factor.

I took my daughter to a doctor’s appointment the other and they gave me an iPad to fill out forms, which I loved as a technologist. A generation X-er given an IPad to fill out the information. I even paid my co-pay on the IPad. It was beautiful. They asked me a thousand questions and it was great. It was death by a thousand surveys type of thing as opposed to clicks. Then I’d go in and the HIPAA paperwork was on paper and I had to sign that.

We still have a lot to do from an engagement perspective. I’m sure that there’s a lot of new apps out there that are trying to streamline that process. It’s getting better. Now if you send me an email three days later asking me for an opinion or a survey on my engagement with the provider, I’m not going to fill it out personally. But that’s changing.

Do you have any final thoughts?

No matter what a vendor or a technologist says, value-based care is a hard journey. It will take us numerous years to figure this out. We have an entrenched system of fee-for-service and we’re starting to see models that can help us to ease the transition towards value-based care. For now, we have the two-payment problem of “having food in two canoes.” I’m still in one canoe, and maybe one of my fingers is in the other canoe. Different markets are doing it differently, but value-based payments are here to stay and we’re not questioning that any more.

My suggestion is to think about it more holistically, more of a long-term plan. Have a one-, three-, five-year plan around engagement with your providers, engagement with your patients, technology enablement, ROI on technology implementations, analytics, and data for actionable insights. All these things have to be addressed. Distribution models, so when the payer gives you a downside risk capitation, how do you distribute that money? How do you make it flow to your providers?

There are a lot of things to think about from a strategy perspective. Be patient. It’s not going to change just because you buy a technology. People and process must be outlined before technology comes into a CIN or a network like ours. But having that strategy beforehand is important.

HIStalk Interviews Erine Gray, CEO, Aunt Bertha

May 20, 2019 Interviews No Comments

Erine Gray, MPA is founder and CEO of Aunt Bertha of Austin, TX.

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Tell me about yourself and the company.

Aunt Bertha focuses on the easiest way to connect people to health and human services programs through a simple interface. I experienced the need for this personally. My mom is permanently disabled. I have been her guardian for the last 17 years. Throughout this journey, I would find out about social programs after the fact. It was confusing to navigate.

I started the company nine years ago to offer an easier way to find programs and to connect to them directly and electronically. Some people call them referrals. We have 73 employees.

The concept of social determinants of health is suddenly popular, but for hospitals, it often just means having a place to record the patient’s self-reported information. Are they getting better at using that information to better transition their inpatients or ED patients to social organizations?

You’re right, there is a lot of talk about social determinants. It used to be called poverty and poverty alleviation. These are difficult problems to solve. The hospital system can do some things in many cases, but in a lot of them, they don’t have much control.

We have 175 customers, of which a good chunk are hospital systems. Many of them are just starting to record the assessments so they can at least uncover problems related to social care. Finding out if they need food or housing is a great place to start. They either turn on assessments in their EHR or they use our assessments.

That’s a great start, but some hospital systems that we’ve worked with have gone really deep. They have staffed social workers and teams who go the next mile and follow up with patients. In some cases, they actually buy wheelchair ramps, groceries, and other things if they find there’s a need.

I would say that the movement is still pretty early. It has been really neat to see how these hospital systems are experimenting.

Is it hard for hospitals to make a quick, clean handoff to community-based organizations that aren’t necessarily equipped to respond quickly?

Absolutely. You still have the issue of non-profit financing. A community-based organization, or CBO, could be a government program or a social service program. Many of them are dealing with long waiting lists and a lack of funding, Some can’t serve their existing population. It is a challenge.

The question then becomes, what is the health system willing to do to engage them further, and, in some cases, to allow for reimbursement for some of these services? We are starting to see the sector think about it. CMS is starting to think about allowing for reimbursement for non-medical services beginning in 2020 for certain situations, if that service is deemed by a doctor to be medically necessary.

The short answer is that it depends. Organizations that sit down with the community-based organizations, get to know them, and build a partnership with them have seen higher levels of success under that model versus just hoping that an underfunded social care network can handle even more demand for services.

These are hard problems. Healthcare should assume longer-term commitments to these financing issues. I don’t think software is going to fix it, to be honest. Even though we’re a software company, I think the broader conversation is, how are the health systems and the local community-based organizations working together?

It’s interesting that 50 years ago, hospitals weren’t very much different from other community non-profits. Somehow their paths diverged and hospitals became monolithic and highly profitable, while most of the rest struggled for funding and hospitals quit talking to them in focusing on delivering episodic services.

You’re reminding me of the book “The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry” by Paul Starr. It’s about how in the early days, people helped each other and how specialization within healthcare then happened. Your analogy is spot on. People did use to look after their neighbors a little bit more and there was tighter coordination. We’ve gotten away from that.

I entered the name of a remote, tiny town on your web page and it returned a list of 800 programs. It was nicely divided by the type of service and offered many simple but powerful ways to filter the list, mark favorites, make notes, and contact the organization. Your website says you have a large team manually maintaining that database versus other vendors who either unethically scrape your data or use a software bot to harvest information from the web. Why is it important to have humans doing the work?

It is incredibly important to us. If you put yourself in the shoes of a social worker or a doctor, they are sitting down with a patient and hearing about things that are happening in their lives. Maybe they need counseling, drug addiction help, or whatever the case may be. You learn very early on that the credibility of our users is on the line. The social worker is sitting down with a patient who is being vulnerable about their situation, which is hard enough. Referring to a program that doesn’t exist or that hasn’t been updated hurts the credibility of the social workers who are out there doing important work. We don’t always get it right, but we try really hard.

We determined early on that we wanted to build an operation of people for two reasons. One, because we think the product and the data will be better. That doesn’t mean we can’t automate some things along the way, and we’ve done some things to make those employees more efficient. But every listing is approved. We try hard to do this across the country, but we focus on states where we have customers and usage because we don’t have unlimited resources. That focus has allowed us to grow.

The team is 25 people and growing. That line item is one of the most expensive aspects of running the business. However, we’ve never spent any money on marketing or public relations. We’ve been able to get to know health systems, health plans, schools, foundations like AARP, and others just by providing a free search. We’ve started to get users that way. It has ended up being a good investment in the business in the long run.

Secondly, it’s a great way to find people in a growing organization. We’ve had many employees graduate from what we call the data fellows program, where they spend a year or two curating the data and verifying information. They become programmers, data analysts, and supervisors. We grow folks and get to know them. It’s a mutually trusted source. They end up doing great things with the rest of the organization.

It’s a win-win, the way we see it. There might be other approaches to maintaining a reliable database, but I don’t think they will win in the long run.

What is your revenue model and how does the community connection work?

We’re doing something different in healthcare. We try to make it simple. Smaller organizations can become a customer at a basic level, a professional level, or an enterprise level. We’ve learned that our customers don’t like seat licenses, per-user per-month models, or other models. We look at it differently than in classic health IT. We’re successful when we have thousands of customers out there paying us a modest amount. That de-risks us. If you are a health system, you can buy our enterprise version with a couple of add-ons at a set amount that is open, transparent, and explained on the website. That allows us to build trust with our prospects.

Once they become customers, we want lots of users. We don’t want to put anything in the way of that. The more users who are on the system, the more people who will get help and the more we’ll get our name out there. Our pricing follows models from outside health IT and it has worked well for us.

It’s also a lot more fun. We only have three salespeople and myself. When a sales team is getting 15 to 20 customers per quarter, they’re having fun. It’s an approach we feel really good about and our customers like that we keep it simple and transparent. This approach to pricing subsidizes the data operations team. We have been able to provide a free service at AuntBertha.com because we have enough customers to cover our costs.

Why is it important that you don’t require people to register before using your online service?

It’s understanding our users. We need to earn the trust of people who are in need, patients in the healthcare setting. We use the term “seeker,” which is basically anybody who is seeking services. Most people are not ready to identify themselves when they’re searching for help for their most intimate needs. Think of a breadwinner who loses their job. Maybe they’re not ready to identify themselves.

It’s an important principle that we allow people to look for things. We see what people are searching for. They are searching for sensitive situations, such as childhood trauma. They have the courage to at least search for help. We want to leave it as an opt-in situation because we build trust. Social workers who work in hospitals or community-based organizations also don’t like creating accounts, so we get their loyalty as users as well.

Once you start making referrals, you can identify yourself and make an account. But we are perfectly fine with users of AuntBertha.com and social workers who are using our platform to pick up the phone and call a non-profit directly instead. It’s perfectly their right to do so and we would not get in the way of that. But from a business perspective, that wins out in the long run and we get customers who want to opt in later.

How do you balance the company’s social mission as a public benefit corporation and your own advocacy work with running a business?

I don’t think they are conflicting. The trade-off in allowing for free users and that social mission side comes across during a deal cycle when we’re talking to hospital systems. Laying out what we’re about and what we’re trying to accomplish is a differentiator in that process. People can quickly tell the difference between an alternate approach that is on price maximization.

We are pretty close to break-even. Our growth and the number of potential prospects allow us to charge less, get lots of users, and still make a difference. We would not be getting into the doors that we’re getting into without the goodwill that we’ve built over the years by providing a free service.

Do you have any final thoughts?

I’m excited about the way healthcare finance is going. I’m certainly not an expert. I was a programmer by training. I worked in public policy with some state health programs. But what I see happening is that health plans and hospitals are starting to become interested in getting the basic needs of people met in non-healthcare or social care ways. They feel like it’s a win-win in the long run, for their government contracts if you’re a health plan, or under alternative payment models if you are a health system.

It’s an exciting time to watch this transformation happen. You’re starting to see teams being formed with the goal of, how can I interact with somebody in need at their moment of need? Could we as a health system or health plan solve that need by building a wheelchair ramp or getting them some groceries? It’s an amazing win-win. I don’t know what’s going to happen with government policy, but watching that is exciting.

HIStalk Interviews Ashish Shah, CEO, Prepared Health

May 15, 2019 Interviews 2 Comments

Ashish Shah is co-founder and CEO of Prepared Health of Chicago, IL.

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Tell me about yourself and the company.

I was previously the chief technology officer for Medicity, where I worked for about eight years leading up to the acquisition by Aetna. I stayed for three and a half years post-acquisition. Prepared Health is a Chicago-based company that is a little over four years old. Our platform connects hospitals and health plans to post-discharge providers such as post-acute care facilities, home care, and social determinants of health partners.

Your new customer Jefferson Health said in the announcement that they want to offer “healthcare with no address.” How are hospitals motivated financially to coordinate post-discharge care?

What’s been happening in healthcare over the last 20 years is a physical re-engineering. For a long time, care was organized around the institution, the community, the beacon, the hospital. Everyone could point to it. But there’s been an overwhelming amount of merger and acquisition activity as pressure increases over cost and improving the access in the community. Sometimes that’s care in the home, sometimes it’s rehab facilities or ambulatory sites. We’re starting to see significant re-engineering of physical assets and communities.

Jefferson is thinking about care not only in those care settings, but also virtually and on demand. You never know when you’ll have a moment that requires a healthcare encounter, so make it easier. President and CEO Dr. Stephen Klasko is a pretty special guy. He reminds me a little bit of Mark Bertolini at Aetna when he talked about quality equaling convenience. Trying to make life easier in healthcare, which is a mess, unfortunately. That’s why I started this company.

Who pays for your system? Do hospitals convince their local post-acute care providers to use it to manage their shared patients?

Like all early companies, we’re not immune to having to figure it out. But in our model today, everyone pays a modest subscription for the platform. We don’t have a limitation on the number of users, the number of patients who are managed, or the number of coordination moments that are managed through our network. That was by design. Part of the challenge is simplifying the entire go-to-market model.

Hospitals pay, but it is our ultimate responsibility to bring post-acute care sites — home health, other home-based providers, and community-based providers – online. That’s part of the value. It’s a difficult job, not only for hospitals, but for health plans, too.

Were hospitals already in regular contact with those post-acute care providers, or is it a new new relationship for the two groups to be at least talking, if not actually working together?

It’s starting to change. A lot of those relationships have been at the social work level. If you had a transitional care nurse or a licensed social worker who was managing that transition out of the hospital, they were the ones who knew the facilities and the home-based providers. It was a personal relationship. That’s how decisions were made on who goes where and for how long.

Cost and quality are bigger topics. You’re starting to see health systems start to invest in new roles, directors or VPs of preferred provider networks or post-acute care in addition to population health roles. There’s more of an effort to try to understand your partners outside of the hospital. The reality is that you can’t acquire enough providers. There will always be a capacity issue. These groups are trying to get a handle on who the very best partners are to invite into their preferred network.

The product screenshots on your site look a lot like Facebook. How important is the user interface when users work for post-acute care organizations that may not use much technology and who may perform all their work on a mobile device?

This is the principal design challenge. It’s extremely important.

If you don’t mind, I’m going to back up for a minute to talk about why I started the company. My father suddenly passed away six months after Medicity was acquired by Aetna. He was way too young. It was unfortunate. We felt unprepared. I was an executive inside of a healthcare business, but over the ensuing months after his passing, we spent time with people who were around him from a caring perspective. He was visited by home health aides. He spent time in senior centers. The toughest thing to understand was that many of these people knew what was happening with him, but there was no mechanism to share that information.

That was the most humbling moment for me. At Medicity, we had connected thousands of hospitals to many ambulatory care sites, yet nothing we we were working on was going to change our family situation with my dad. As I dug into the problem, there are 100,000-plus sites of post-acute home and community-based care. That’s being conservative. The challenge is a design challenge. How do you quickly organize a large ecosystem that the majority of the market says has no money? Why would you focus on that? Yet we know it is super critical.

When I left Aetna and Medicity, we looked at models like Facebook and LinkedIn. Although we had made nice progress, Facebook and LinkedIn had organized billions of users. Although our business model is not the same as theirs, there’s something to be learned from their design approach.

Sometimes technology just makes a process more efficient or transparent, but your platform does something that can’t be accomplished otherwise. You can’t get everyone from all these provider organizations and family members together at the same time in a conference room or conference call.

We are in a crisis right now as a country. Ten thousand people are turning 65 years old every day. People talk about the silver tsunami. It’s going to tax the healthcare ecosystem in a significant way, but 47 million people in the US are unpaid family caregivers. These are people who care and who are willing to do whatever it takes to take care of their loved one, but they have no coaching, no training, no access, no connectivity.

As much as I love many of the great healthcare IT companies that are out there, no one is really focused on this part of the space. What health systems and health plans are starting to talk to us about is that personal caregivers, family caregivers, somebody in the community, or post-acute care providers make up an important group of teammates that they need to get connected and coached.

What kind of interaction do family members typically have with the platform and the provider care team?

Our first version was full transparency, just the way I wanted it when I started the company. It’s not uncommon to see home health staff and all the different workers connected to the family members around an individual. Or maybe a skilled nursing facility is also involved. Everyone is in together.

The types of things that people are doing are escalations and managing interventions. If somebody has a fall in the home or if there’s a sudden change in mood or weight gains, those are prompted by the professional care team to the family members and communication around those moments is being managed. These are difficult moments for families and there’s a lot of emotion in these conversations. What we’re most proud of is that through our implementation, we’ve seen these two groups turn into one team versus two teams that sometimes let emotions get the best of them.

As we think about scaling that experience, our provider organizations have coached us to think about how to keep the convenience and access in place, but to think about this as two modes of communication — a back office communication channel where things are communicated in shorthand and then a front office communication channel where you have buttoned up or polished communication with the patient and family. The concern is always that somebody will say something that makes the organization look bad. We’re working through that with some of our earlier customers.

It would seem beneficial to allow caregivers who work for different organizations and who may rotate assignments to have a closed channel that allows them to take a conversation offline.

We’ve paired group-based communication with individual communication. We’re trying to attack any mode of communication. That could be an assessment, an electronic check-in on how you’re progressing, a referral, or a transition. We incorporate group and secure texting and chat into the product. Interestingly, we see high utilization of all of these across the board.

The magic is communicating with somebody outside your organization. That’s the biggest challenge. I spent 10 years working on data interoperability in healthcare and God bless everyone who is trying to push all that stuff forward, but I think we have skipped over the fact that a number of these types of things will never happen through an EMR. People don’t talk through EMRs. They don’t manage interventions in real time through EMRs.

What kinds of things does your virtual care coordinator recommend?

DINA is our digital nursing assistant. She was an accidental invention. It started with how we could create this rapidly growing ecosystem or community for communication. In our first implementation, we met Amie Martinelli from Bayada Home Health Care. I’ll never forget her. She did an amazing job of coordinating care for complex CHF patients. When we looked back at the implementation, we thought, how will we ever scale Amie? Is this what everyone in healthcare is doing? As we studied more, it is what everyone is doing.

Every great outcome is an exception. Someone has to put forth a heroic effort to make sure all the right things happen. That’s hard in a market where there’s 40-50% turnover. We thought that a combination of advanced analytics, AI, and all the other buzzwords could be an answer. Today, DINA is present in our network and she is aware of all the communication. When people integrate their data with our solution, we get our hands on rich functional, behavioral, and other types of assessments. She can recommend people who perhaps should have a particular type of service, who could be seen at a more optimal care site, or whose situation should be escalated.

One that stands out is hospice. Sometimes people are on home health for a long time. They are re-certified over and over and over again. A lot of that is because of the personality of a nurse. They never want to quit on a patient. We’ve taught DINA to identify that moment where perhaps it’s time to have a more difficult conversation around palliative care options or hospice. One of the things that you’ll never find in a hospice eligibility guideline is the inability to use the telephone, but our predictive models found that to be a huge predictive factor.

DINA is aware of a lot of the communication. She can recommend people for conversations around hospice or perhaps a readmission back into skilled nursing versus a hospital. She’ll notify people when they are crossing certain care guidelines. If somebody should have been in a skilled nursing facility for 10 days but they are on their 15th day, she will identify that and communicate it upstream. She can do a lot of things, but much of it involves intervention management.

The Jefferson Health contract gave the company a lot of visibility given its relatively modest amount of funding. Where do you see the business going?

We have been humble and quiet by design. We bootstrapped the company for two years because David Coyle and I were focused on understanding the market, solving a problem, and generating some revenue along the way. We raised a modest amount of money, $4 million, to build a team and enter a new region. We’re active in three states — Illinois, Pennsylvania, and New Jersey. We’re proud of the work in that greater Philadelphia market, which is a top eight metro market. We working not only with Jefferson, but also Holy Redeemer. Almost every major home health provider in that region is on our network and soon we’ll be adding many of the leading skilled nursing providers as well.

As we scale the business, we’re looking to take this national. We just added a new senior vice president of sales and marketing, which is a brand new role for us. But we feel like we’ve been doing this the right way. We didn’t oversell. We didn’t over-promise. We did the hard work of trying to understand the space and create a great product experience. We’re maniacal inside the company around Net Promoter Scores and engagement of the product. We stand on a solid foundation. That’s what we care about first and foremost. Do we create value, and do we create it at a faster rate than anything else that’s out there?

With a few wins under our belt, it’s time to pick up the pace on building the business. We have identified hot spots across the country where there’s a greater need, where Medicare Advantage and managed Medicaid in the aging population is growing faster than other places. We will zoom in on those as a starting point. We’re in a good spot to start to scale. We see a lot of companies that try to scale too fast. We’re in the right place at the right time, but we have to do the work like everyone else.

Do you have any final thoughts?

There have been a lot of competing incentives and sites of care. Nobody is trying to do the wrong thing. But the next major wave is Dr. Klasko’s “healthcare with no address.” Internally, we call that a never-discharge mindset. How do we care for an individual when they’re healthy, they have an acute need, or they move into the post-acute ecosystem? With the amount of M&A that’s taking place and the amount of change that is required, we need more people to adopt this never-discharge mindset. The caring never stops for the family or the individual, so it shouldn’t stop for the institution.

HIStalk Interviews Stephen Brown, Director of Preventive Emergency Medicine, UI Health

May 8, 2019 Interviews No Comments

Stephen Brown, MSW, LCSW is director of preventive emergency medicine at University of Illinois Hospital and Health Sciences System.

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Tell me about yourself and your job.

I’m director of preventive emergency medicine at University of Illinois Hospital and Health Sciences System. I run the Better Health Through Housing program, which identifies the chronically homeless in our emergency department and transitions them into permanent supportive housing. We’ve been doing this since 2015.

My background is in technology. I worked for Motorola for 13 years in a variety of capacities, starting off as a junior systems engineer and then ending up being a district sales manager. I was also a product development manager and a senior account executive. I transitioned into healthcare in 2005, working in the emergency room at the University of Chicago as a social worker on the South Side of Chicago, surrounded by 10 of the 14 poorest neighborhoods in the state of Illinois. Then I transitioned to University of Illinois in 2011 to start a preventive emergency medicine program.

What motivated you to move from a technology and sales career to becoming a social worker?

I always loved the technology, but being in sales, you’re only as good as your last sale. I just got tired of living under quota. Plus, after doing some career development things, I discovered I was an introvert and that was why sales was so painful for me. [laughs]

It was a career transition, a mid-life transition. By 40, I decided I wanted to do something that was more altruistic. I originally was going to become a psychotherapist and start my own private practice, but I worked for Michelle Obama at one point in my career at the University of Chicago. We had some discussions and I decided that I wanted to do bigger work than just one-on-one counseling. This was an opportunity to do more population health work.

Does simply giving someone who is homeless a place to live help reduce the high healthcare costs they incur, or is the next step to identify and address any underlying behavioral or dependency issues?

This partnership has been with the Center for Housing and Health, a supportive housing agency here in the center of Chicago. They have relationships with 27 agencies scattered around the city.

What we’re learning is that it’s a tiered approach. Many people will just require what we call rapid re-housing. We don’t quite have the answer, but we’re in conversation about tiering the approach based on psychiatric and substance abuse characteristics. They are medical conditions for homeless individuals. We had somewhat of a lower level. It was scattered site housing. It was permanent supportive housing, but it came with a housing case manager, somebody who’s not trained in medicine or in psychiatry. Despite that, we still had good outcomes.

Are views changing on our expensive system of providing healthcare services vs. funding social programs and public health projects that might reduce the need for them?

Some studies have been done on that. We have great sick care in the United States. We wait for you to get sick, and generally you’re going to be sicker because you haven’t had preventive services. We don’t do prevention, nor do we address the social determinants of health.

There have been a number of studies around around the world where the relative spending on healthcare is much lower. I think we spend 2.5 times per capita for healthcare here in the United States compared to other industrialized countries. Healthcare costs are excessive. I think it’s approaching now 17% of our GNP.

But the other thing that is missed is that other industrialized countries spend more on social services and on prevention services. Having a safety net in place goes a long way toward preventing people from getting a lot sicker. That’s where a lot of the attention is in healthcare now, what we’re calling the social determinants of health. If you don’t have a stable place to live, it’s difficult to manage any of your health affairs, let alone anything else in life.

We’re really good at individual care here in the United States. We focus on the individual. What has been missing in healthcare is hospitals taking responsibility for the health of the communities in which they serve. After all, I think it’s 78% of the hospitals in the United States are non-profit and must demonstrate some type of community benefit to maintain that non-profit status. That shift in focus says that we have to care about the health of the individuals coming from the communities in which we are anchored, and yet that’s been a big disconnect in healthcare.

The technology exists to be able to create community-based report cards. Hospitals should be held accountable for the health of those communities in which they serve. There’s a way to do that through clinical measures, like aggregated hemoglobin A1C in a community, blood pressure, and number of ED visits for asthma exacerbations. Those are all things that are measurable and that health IT could take an active role in bringing forth. That creates accountability for hospitals — perhaps even a collection of hospitals if they serve the same geography — to take ownership of the health of the individuals within those communities.

The alignment is clearer if the health system is also the insurer, such as Kaiser Permanente. Health systems keep getting bigger and spanning state lines. How will those mega-systems work with the many communities in which they operate?

It remains to be seen. We are seeing some activity from Geisinger and from UnitedHealthcare. United Healthcare Is working with the American Hospital Association to develop 20 new ICD-10 codes for social determinants that would be actionable. We can document these things, but unless we take action on those social determinants, they’re really not going to go anywhere. I’m in conversation with a Denver health plan right now about replicating the model that we’ve created and a number of other health systems around the country.

The most interest is coming from those integrated health systems that are both the provider and the payer. It’s in their economic best interest to prevent people from getting very, very sick. We’re beginning to get interest from managed care organizations, too, many of which are represented by larger health insurance companies.

In any state, 5% of the patients in Medicaid account for about half the budget. Generally those budgets can consume about a third of the state budget. Because we’ve been so focused on individual care, we’ve lost the forest through the trees on those. There needs to be some attention on more of a population health model, not only at the state and federal level, but also within some of those large health systems, too. There’s tremendous opportunity to manage the health of these individuals by looking beyond the walls of the hospital and saying, what is it in a community that is driving the exacerbation of disease and poor outcomes?

How you see the pacing of the buzz about social determinants of health being matched by the creation of programs that will make them useful for actually changing something?

What happens with social determinants of health is that we try to do it the old, inefficient way. We hire a bunch of people. We screen in emergency departments. We’ve had some experience doing that. We’ve only been able to hit maybe 2% of the entire ED population because we’ve done it in the manual way. Again, here’s an opportunity for tech to get involved. When you bring big data to bear on this issue, you can find lots of things that you can elevate for risk and make it actionable.

Adverse Childhood Events, or ACE, is being promoted by the CDC. The chronically homeless fit the same profile over and over again, as 60% of the chronically homeless or the homeless in general have what we call high ACE scores. It’s a 10-question questionnaire that predicts poor outcomes, the development of psychiatric illness, and early death, among a variety of things. It’s kind of astounding.

We found that our chronically homeless individuals fit the same profile over and over. You’ll find this is true in criminal justice, too. The higher the ACE score, the higher the probability that person is going to end up on welfare, will have a mental illness, will end up in the criminal justice system, and will die early. One or both of the parents had mental illness or substance abuse and it played itself out on a profile where that person ended up becoming chronically homeless and developed serious mental illness.

You can find those things in a combination of electronic medical records, in public data, and in credit data. A number of emerging companies are looking at data mining to find those folks who have elevated risk. For example, with classical homelessness — somebody who has fallen off the grid because they’ve had some financial catastrophe or income volatility in their lives — you can find those people easily in credit data. You can predict the risk of homelessness eight to 12 months before it actually happens.

The way healthcare responds to that is inefficient, but there are opportunities to find people with a high ACE score and intervene with them early, because you’re going to see it play out in a lot of different things that are going to result in poor outcomes.

I’ll give you a vivid example. When I worked at the University of Chicago, there was a lot of crack cocaine on the South Side of Chicago. We would often get women who had cocaine intoxication. They were hyperkinetic or manic. Once we allowed them to detox on cocaine, I’d go in and interview that woman. The doctors were focusing on whether or not she was going to have a heart attack, so they were looking at elevated troponin and all these medical characteristics. They had a medical course of action. They were treating the symptoms of what is a greater problem.

When I dug into it, I found that the typical scenario was that the woman that had been repeatedly sexually abused when she was eight years old by her stepfather or uncle and had undiagnosed PTSD as a result. She had a very high ACE score and we hadn’t done anything. We got her treatment for her substance abuse, but she probably needed treatment for PTSD, too.

How can technology fit into a program like yours?

The big piece of it is bridging the gap from healthcare into the community. The FHIR standard is a promising technology, but as we found with the CMMI Accountable Health Communities, there is a substantial gap in tech between health IT and community IT. Many people are still dealing with spreadsheets. If the provision of a social service or community-based services is going to be effective, we need to be able to track whether or not that person actually got the service. Then, was there a treatment effect from that service?

What we’re doing here on the West Side of Chicago with the West Side United effort — a collection of five hospitals — includes a lot of economic development. Things like wealth management classes. We’re doing local sourcing for our supply chain. We’re trying to partner with colleges to create a talent pipeline and steer kids in the community into careers in tech and healthcare.

But beyond that, we need somehow to bridge the gap. Some of the things we’ve been talking about is giving out case management solutions, so we have just one platform for the community that can provide data on the receiving end. Those are going to be some of the biggest challenges we’re going to be facing if we are really going to tackle these social determinants of health.

The other thing is that I’m a big believer in microservices and having the ability to have an app store kind of arrangement for human services. Something that is plug-and-play and easy for JavaScript programmers to integrate and exchange data with healthcare organizations. But we’re going to need some enabling technology on that. We have a grant with the JB Pritzker Foundation to do cross-sector data exchange. In order to drive clinical integration of systems, we’re going to need to be able to have some kind of common appliance that can manage the traffic and flow of messaging and interoperability between human services and healthcare. This is a particular issue here in Chicago because we don’t have a healthcare information exchange.

The other piece of is from an evidence-based public policy, to be able to track individuals and their service utilization. In an ideal world — especially with these homeless individuals that we’ve found to be very, very expensive — we’re only looking at the most obvious cases. But as a population, how could we look at their healthcare costs? We know they have elevated healthcare costs, but do we know for the entire homeless population what that looks like? We’re only looking at mostly the chronically homeless, those who have been continually homeless over for a year. We need to have more resources available to do interoperability for both clinical integration purposes and to bring together large public health data sets so we drive evidence-based public policy.

A fair amount of national empathy seems to have been replaced with resentment toward social programs and those they help. Is there a message of hope that these programs work and will be accepted?

You see these bright spots happening around the country. Bexar County, Texas, which includes San Antonio, has a psychiatric stabilization center where they divert people in psychiatric crisis to a center where they are treated. They don’t have to go to the ED or jail. There’s a lot of good work happening. It just doesn’t get publicized because it’s a little bit wonky.

My job is more public policy and aligning systems so that they talk to each other. I think that we’re going to see some tremendous benefits from those things, because no matter what your political affiliations might be, we’re discovering that at least with some of these populations, the solution is cheaper than the problem. We would all feel better about ourselves if we look at how we can care for these people in ways that will extend their lives and keep them from getting sick. It’s also the right thing to do.

Here in Chicago, we’re having extraordinary conversations with the jail, with Cook County Health, the other public hospital here, and with Illinois Department of Corrections. We’re creating a flexible housing pool that will result in more supportive housing, with about 750 new units coming online. We haven’t borne the fruit of it, but I’m optimistic that we’re going to see some major sea change in how we treat the homeless and other marginalized populations. Especially non-violent offenders. Can we offer them alternatives to prison or jail? I’m seeing a lot of work in the opioid crisis right now. The sheriff’s department is creating a diversion unit. Hospitals are learning that if you want to treat the opioid crisis, you have to go out to them. They can’t come to you.

The glass is half full, as far as I’m concerned. We’re doing a lot of great work that will bear fruit very shortly.

HIStalk Interviews Dan Dodson, President, Fortified Health Security

April 29, 2019 Interviews No Comments

Dan Dodson is president of Fortified Health Security of Franklin, TN.

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Tell me about yourself and the company.

I’ve been in healthcare for most of my career. I have always been inspired to give back to healthcare and patients. I have an MBA in health organization management and have always been intrigued at the concept of using my business degree to help provide better patient experiences. I’m blessed to do that at Fortified Health Security.

We are a cybersecurity company, a managed security service provider. We provide a wide range of managed services to healthcare organizations to help them combat threats and comply with regulatory requirements.

How does a health system decide where to focus their cybersecurity efforts and funding?

I have that conversation with organizations every day. The majority of healthcare organizations understand that it starts with a risk assessment. Pick a framework and do an assessment. From there, figure out where you have deficiencies or opportunities for enhancements. Every health system is different on what their next step will be, but the core of every good cybersecurity program requires performing an assessment of where you are, then driving your strategy from that.

Then, think about the perceived value of your cybersecurity spending and the actual value that you are receiving. A lot of organizations look to buy the next shiny security tool. The board and C-suite perceive that the purchase of that technology will better protect them from adversaries and from hackers. That is true to some degree, but when we implement those technologies within a healthcare environment and its many nuances, we lose sight of what we actually need to do to operationalize that technology.

I encourage organizations to think about not only how they are deploying capital for buying new technologies or implementing new services, but how they are making sure that they are working in concert with prior investments whether they are supporting them operationally to extract the value that they perceive those tools provide. Tools can be quite sophisticated, but they require people and process to extract their full value. We see a lot of under-implemented, underutilized technology in healthcare organizations that we work with.

Sensationalistic headlines talk about theoretical risks that have never actually happened in the real world, such as medical device hacking and inserting malware in medical images, which doesn’t seem to offer much incentive for a hacker. Are hospitals chasing those hypothetical problems instead of the duller but more dangerous ones that don’t make headlines, such as the usual email-launched attacks?

Certainly some companies and folks are chasing those headlines with their solutions. No single bullet will protect you and secure you 100%. You have to take a layered approach that is appropriate for your organization.

We do a lot around medical device security. The threat to medical devices is real, but we are seeing it manifested by adversaries and hackers using them as a jumping-off point to get to the valuable data, not necessarily to disrupt the clinical performance of that device. They use the medical device to get to EPHI.

What new cybersecurity threats have you seen recently that are most worrisome?

We are seeing a lot of just the fundamental attacks, such as insiders and users and clicking on bad links in email. Those are still some of the highest threats that face organizations. Attacks such as phishing and vishing are increasing and becoming more sophisticated.

We encourage people to think about the fundamentals of a security program. The unsexy things — patching, making sure that they are doing vulnerability scanning, making sure that they are identifying where they have EPHI, monitoring the networks, and looking at logs. The traditional core fundamentals. Often when we peel back the layers of what happened in a big breach, a user inadvertently or purposefully did something, or there was a lack of internal blocking and tackling for security. We encourage folks to think about whether they are executing a good, solid fundamental program before investing in the latest and greatest gear and tech.

Organizations that are forced to admit that they have been breached always claim it was a sophisticated attack and sometimes imply that a state-sponsored hacker was involved, perhaps to make themselves seem to the public to have been more security-aware than they really were. That can lead the organization’s cybersecurity insurers to refuse to pay their claims because they can say that implicating state hackers suggests an act of war that their policy doesn’t cover. What is the level of threat from state-sponsored hackers in healthcare?

Healthcare is vulnerable. ARRA and HITECH spurred rapid digitization that wasn’t always implemented on modern, secure networks and infrastructure. The increased amount of valuable electronic health information is stored on the path of least resistance. State-sponsored attacks and hackers look for the path of least resistance, so we are vulnerable at the onset.

You brought up cyberinsurance, which is important to understand. Procurement of cyberinsurance in a healthcare organization may or may not involve IT or security. It might be procured by the legal or compliance department. A cyberinsurance policy’s actual insurance binder contains the requirements for that policy to be in force. It is important that organizations know what’s in that binder so if they have an incident, they actually get paid.

We are seeing that during the claim review process, cyberinsurers are doing claw backs or denying claims because the organization wasn’t meeting the requirements contained in the insurance binder. That’s a critical area of focus. Don’t get a false sense of security just from having cyberinsurance. You have to make sure you are doing whatever the binder requires. It has gone unfavorably for healthcare organizations that failed to do that.

Why do we keep seeing major information exposure from unsecured servers that are open to the Internet?

Networks have sprawled over time with health system acquisitions and consolidation. We see that every day. This cobbled-together infrastructure and process allows it to happen. We are all shocked when it happens and of course we want to avoid it.

It goes back to the fundamentals and looking at root cause. We need to have asset inventories, know where our EPHI is stored, and understand how it is performing on our network and within our environment. Spending time on the blocking and tackling fundamentals reduces the chance of finding yourself in that situation.

Quite a few breaches were caused by a health system’s third-party vendor. Has anything changed with regard to the role of business associate agreements in a security plan?

It is important to understand third-party risk, the types of data you are sharing, and how you are sharing it. The lines of responsibility have become blurred within the context of those types of relationships.

It’s important to have business associate agreements in place. I always chuckle when I say that because we still find people not doing that. Then it’s important to have risk stratification of those third-party partners to make sure that you understand what they’re doing from a security perspective to better isolate the data that we create and that we’re responsible for safeguarding.

How common is it for a health system to have a chief information security officer position that is staffed by someone whose credentials would qualify them to work outside of healthcare?

There’s a human capital problem in cybersecurity for all industries. Depending on what rags you read, millions of cybersecurity jobs are open worldwide at all levels. As you narrow that down to healthcare specifically, we see that a lot of the larger organizations have a CISO on staff full time. When you get to the mid- market, they probably have a person who is dedicated to security, but who has other functions as well. The organization may engage in some type of virtual information security offering to offset that, to bring in expertise and guidance without necessarily keeping somebody full time.

The big challenge is that the role turns over every couple of years. Folks do not tend to stay long in this job. That can cause challenges for the healthcare organization because they’re changing strategy every couple of years when the leader changes.

Do you have any final thoughts?

We are in an interesting time with cybersecurity and the threat landscape. I’m encouraged by the progress that most organizations are making in this space. I encourage everybody to continue to focus on the fundamentals. To those who have partnered with Fortified and our employees, thank you for driving our mission to increase the security posture of healthcare.

HIStalk Interviews David Wenger, CEO, Bridge Connector

April 24, 2019 Interviews No Comments

David Wenger is founder and CEO of Bridge Connector of Nashville, TN.

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Tell me about yourself and the company.

I’m the founder and CEO of Bridge Connector. Bridge Connector is an integration platform as a service with a data-driven workflow automation solution. It is focused on solving the business workflow aspect of healthcare and creating interoperability between systems and ease of communication without the need for code. It is a truly scalable platform that provides an affordable solution to any sized healthcare organization so that they can streamline their business use case workflows.

It’s unusual for someone with no healthcare or IT background to be diving deep into the technical aspects of interoperability. How did that come about?

I grew up around the medical field. My dad’s a doctor, a businessman, and an entrepreneur. I watched him my entire life and learned from him about healthcare and why it’s broken. I’m an entrepreneur. I started a marketing and advertising agency about six years ago that focused on branding, marketing, web development, and cool tasks like that. It focused on helping smaller healthcare systems, drug rehabs, and behavioral health facilities with marketing to get customers in the door as well as keep customers or patients. I learned healthcare through that.

I saw a really big problem with one of my drug rehab clients. We were hired to integrate their Salesforce instance with their electronic medical record software. They were getting 150 phone calls a day and had a full team of people in their office typing the information manually from one system to the other. It was a 30- to 45-minute process per patient. I said, we can build this integration, and it took about six months.

After we built that first integration, I thought that there must be a faster way to do this, where any of these drug rehabs or smaller healthcare organizations could connect System A to System B without having a full team of people trying to build the integration on a custom basis or manually typing the information back and forth.

My father owns a surgical center under Envision Healthcare, which is a very large company. I spoke to people at the company and learned that this is a problem across all of their surgical centers and doctor’s offices. They have no way to get the data from the doctor’s office to the surgical center, or vice versa, without having to manually type the information back and forth.

I decided to do more research and build a proof of concept. I hired some smart developers and bootstrapped the whole thing out of my own pocket with some help from some friends and family. We built and deployed a fully-functioning, working prototype. We partnered with companies like Salesforce, for example, in taking this to the masses, focusing on smaller businesses at first and scaling it from there.

Systems can talk to each other in many ways — FHIR, APIs, app stores, and traditional vendor interfaces. What are the technical and business challenges in solving the interoperability problem?

There’s a lot of standards out there, and a lot of companies that are stuck with the systems that they have. The solutions that are coming out are around API management or coding to specific APIs to build integration, so that developers have a tool they can easily use. We’ve taken a different approach. We have focused on meeting our customer at the spec their core system uses, whether it’s FHIR, HL7, API REST, SOAP, or a on-premise server solution.

We’ve created a way to connect to any type of standard and not make our customer have to code to any of those specs. We do it for them. Our platform is capable of digesting any of the types of information into one to make it a truly functioning integration. A solution like ours can go to the masses and be deployed to any type of healthcare organization, regardless of what system they’re using. As long as there’s a way to connect to that back-end system of truth or the other systems of truth, we have a way to do it, regardless of what standard they’re using.

What developments have you seen in making sure the information being exchanged makes sense to both sides and that it is inserted into the workflow at a point that makes it actionable instead of just making it available for a manual lookup?

We are focused on solving the business problems of healthcare. The problem in healthcare isn’t just clinical data. It isn’t just sending data back and forth. The problem is automating the business problem of healthcare. What drives physicians, what drives hospital organizations, isn’t just the money and patient care, but it’s automating the workflow so their daily processes can be as smooth as possible.

The government is saying to focus on interoperability. They’re trying to put a focus around it and develop it, making sure EMR companies or other vendors have fully-functioning APIs or FHIR standards. They are focused on trying to solve this problem. Companies like Bridge Connector and some of the other players out there are focused on building a standard that any sized system can easily connect to.

How do you work with traditionally low-technology, small-scale providers such as long-term care facilities and small medical practices?

We’ve partnered with the EHR companies in the long-term, post-acute care space. Their customers are requesting this type of integration and the ability to have their data flow easily. We partner at scale with a Salesforce, Clinical Care, or Brightree, for example, and provide a solution to all of their customers. The unique part about our platform is that once we build the connector or build an integration with one vendor, we’re able to rapidly deploy it again and again and again without the need for code.

Time to value, especially from a marketing brain, is everything. The faster you can go live, the better. The longer it takes, the more money the organization is losing. These smaller-sized facilities that aren’t at the leading edge of technology are trying to find ways to streamline their data so that they can solve their business workflow problem and then maximize their revenues by automation.

How does your social determinants of health functionality work?

We are launching our social determinants of health application. We’ve built a fully-functioning application on top of Salesforce. Anybody who owns Salesforce, such as a payer or large provider, can download this application that we’ve built — when it becomes available in the next month or so — and provide social determinants of health within their Salesforce org. They’re not only automating their workflow with integration and utilizing Salesforce to have all their customer data in one customer-centered place, but now they will be able to remove the barriers of care to their patients through this application that they can automatically deploy within their existing Salesforce org.

Salesforce made some healthcare-related announcements a couple of years ago, but I’m not clear what they are actually doing or who is using their product. How do you partner with them?

They are obviously a very, very fast-growing company. They have a significant interest in the healthcare space. They’re are doing a great job of providing value to the customers from a business perspective and automating that customer-patient view.

We partner with Salesforce to help the customers that they’re signing or customers that need integration. We partner with them to help automate those integrations and make them faster and make them easier to deploy, providing affordable solutions so that they can focus on what they need to focus on, which is obviously taking care of the patient.

Salesforce enables them to market to their patients and to schedule their patients. The functionality of Salesforce in healthcare is extremely impressive. We’ve been happy to partner with them and are excited to see where that goes.

What’s it like working with Salesforce, which was built on the concepts of openness and partnerships, compared to an EHR vendor?

Some EHR vendors have been slow to recognize that their customers want to be able to have the data flow as it needs to and to get the reporting that they need easily. The goal isn’t to take the data out of the EHR or make the EHR any less important to the healthcare organization. The EHR is important for the success of the business from a healthcare side as well as the patient.

The reputation of that openness of data is growing. EHR vendors are grasping the need and responding to what their customers are asking for, with integration and being able to have the data flow wherever it needs to. Obviously in keeping it secure and removing the identifiers and stuff like that. Salesforce is extremely secure. Bridge Connector is extremely secure, as well as the EHR. The core focus is taking care of the patient data and making sure it’s as protected as possible.

The company has grown quickly in headcount, customer count, and funding, but some see the healthcare IT market leveling off to some degree. How do you see that growth continuing and what will drive it?

We launched a year ago and we’ve raised $20 million so far. We had five people about 14 months ago and now we have 75 full-time employees. There’s such a need and so much customer demand for integration. Interoperability as a buzzword is more than just sending clinical data back and forth or patients having access to their medical records. The problems exist with the business use case. The markets that we’ve targeted, such as hospitals, are at the leading edge of technology.

We’re focused on the commercial space of healthcare. We are solving that business problem for those commercial vendors that can’t necessarily afford to spend money on a custom integration or developers building out integrations. They need is a rapidly deployable, affordable solution that generates immediate ROI.

We’ve grown so fast because of that, how we’ve partnered, and who we’ve partnered with. The overall need in the marketplace for a solution like what we have is driving our growth. Our growth is pretty astonishing to me, as someone who’s been here since the beginning and saw the idea and where it has taken us.

I think we are just getting started, to be honest. I think the growth will continue. We’ll continue to double in size. We’ll continue to rapidly increase revenues and customer counts and provide a solution that’s easily deployable to the masses over and over and over again, and at scale. We’re looking at hundreds of systems being rapidly deployable without the need for code over the next six to nine months. In healthcare, that solves a huge problem.

While the market might be leveling off a little bit, we think it will hit another inflection point in the next six months, where we will just continue to scale rapidly.

Do you have any final thoughts?

Healthcare is a semi-broken industry. Doctors need to focus on taking care of patients. A guy like my dad, for example, goes home every day after seeing 35-40 patients and types notes or does follow-up work on each patient. It’s an extremely draining task because of the need for notes or documentation, which are important, but there’s no way to easily do that.

The faster that the healthcare market allows for full interoperability or full connections between systems without EHRs getting in the way, from a API being available or charging customers lots of money to be able to have these integrations. As the market keeps growing, there will be a continuing need to connect systems, make the data actionable, and let the business automate workflows, Otherwise, the healthcare industry is not going to get fixed.

The way to fix it is to first solve the business problem, allowing System A, B, C, and D talk to each other. They can do that in every other industry in the world. Why can’t we do that in healthcare?

As a company that has grown as fast as we have, we feel that over the next year, we can help provide that solution to the masses. Not just hospitals, not just large enterprises, but to a small doctor’s office so their system can talk to other doctors’ offices, or have it talk to their billing system without having to go to their EHR vendor and paying thousands of dollars on top of the actual integration costs. The goal is to be able to deploy this to the entire healthcare market, not just the enterprise.

HIStalk Interviews Luis Castillo, CEO, Ensocare

April 10, 2019 Interviews 1 Comment

Luis Castillo is president and CEO of Ensocare of Omaha, NE.

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Tell me about yourself and the company.

Ensocare is a care coordination platform that helps move patients to the right level of care along the care continuum. We’ve been doing this for about 10 or 11 years and I’ve been there five years.

I’ve been in healthcare IT for a long time. I don’t think I’ll ever go back to big company. I’m having the time of my life running this small company.

What are the benefits and challenges for hospitals in getting discharged patients placed and coordinating their care afterward?

The big EMR push, Meaningful Use, and even ICD-10 took people’s attention away from the post-acute care side. What happens once you leave the hospital? I lost my brother about two years ago and I remember trying to get him placed into hospice. I had to go to our network and ask my team. Who is available Des Moines area? What are their CMS scores? Because the hospital handed me what looked like the cardboard filler that comes in a shirt. It was laminated and had a bunch of numbers on it. Some were scratched out, some were written over.

They said, here you go, it’s up to you. Make some calls and figure out where to put him. There was no automation and no ability to tell me which facilities were better or which ones weren’t. That discharge and placement process is highly fragmented and not very process driven.

We put automation and technology behind this very manual place. Nurses typically stand in front of a fax machine for 5-6 hours a day getting this done, so we let them go back to working at top of license and get them back in front of the patient — case managers, social workers, and so forth. But we also impact length of stay, so if I can decrease it by a quarter-day for patient population, that’s big money over the year.

Hospitals sometimes leave placement decisions to the patient and family to make sure they aren’t accused of playing favorites or being held accountable for placements that don’t work out. Is their challenge in advising patients and families due to lack of knowledge or a reluctance to exert undue influence?

That’s a really tricky question. I still remember when health providers and payers couldn’t even be in the same room together. There was this hatred for each other. But now health plans own hospitals and hospitals create their own health plans. With some of the Medicare Advantage plans, people who are taking on risk can manage and direct patients to places if it’s their own population.

But you bring up a great point. The IMPACT Act says you have to give a patient choice. You have to disclose any financial relationship you have with that home care agency or that behavioral health provider that is affiliated with your IDN.

Our system lets you put all the choices in front of the patient and give them an unbiased score, such as the CMS scores for quality. They can flip through almost a Hotels.com interface on the tablet and look at the places that have a bed available. They can see if they are pet friendly, check which churches are nearby, see a picture of the area.

Hospitals aren’t supposed to direct people or to steer them. They have to manage that closely. Our application helps document that they gave the patient choices.

In the absence of something like a Tripadvisor that includes detailed reviews and scores from individuals, should I as a patient or family member trust the CMS star ratings?

We’ve been asked by our customers to do some kind of independent rating score for post-acute care facilities based on the data that we have, such as readmit ratios and quality scores. But I’ve been hesitant to do that. We offer the post-acute care network a free portal. We don’t charge them to belong to this, although some of our competitors do. We try to get them to be engaged, to answer inquiries within 30 minutes, and to keep their engagement level up.

We have something that is more on the predictive side on our roadmap. Predictive analytics that say, based on what we know of this patient and the performance of organizations in our network, here’s where we think this patient will do best. They need DME, infusion, dialysis, and these levels of care, and these places do really well with that. I don’t want to become a Class II device and make a clinical recommendation, but I will start scoring and show them a predictive model.

How important is it to have access to actual empathetic humans and not just technology and information when making what could be one of the most important decisions in someone’s life?

I remember when Gateway and Dell came into the PC market. Nobody thought they would ever pick a laptop or desktop off a pick list since technology was intimate in some ways. You wanted to see it and touch it. You would never buy it sight unseen. But the paradigm has shifted. We buy online, even for major purchases like cars, and just have it delivered.

You probably won’t pick a provider via technology, but you’ll get a list of 10-12 places that have a place for Aunt Betty. You take a look on the tablet at their quality scores and decide which three to visit because they meet the criteria. You’ll physically go and take a tour to see if it’s the right place.

The predictive modeling will make it more interesting in being able to show outcomes and recommendations. I’m not sure if I’m going to develop a Yelp-like thing, but people want to know what other people felt about their visit there and what it was like.

It’s also true that everybody is not in the same financial situation. We are looking at working with payers to provide an estimated out-of-pocket expense. That is powerful because you may not be able to afford the five-star rated place.

Given that not everyone is willing or able to pay for a Ritz Carlton, can someone with a Motel 6 budget at least look up how satisfied others like them with similar expectations were with a particular facility instead of just comparing absolute satisfaction numbers?

Not today. The closest thing involves discharges, although it’s hard to quantify with so many variables and I can’t say for sure if I’m impacting it. But we’ve seen a big change in HCAHPS scores. On discharge, people afterwards didn’t understand the discharge because it was in the wrong language, she spoke very quickly, they were pushing me out the door, the ambulance was late. They list all these things, but an HCAHPS-type measure does not exist for the post-acute care visit right now. But as you start managing populations, I think it’s coming.

What does a hospital need to do to get started with your program?

They start by listing their favorite facilities in the area, the ones they use frequently and discharge to most often. We build that into a quick list in the system. We reach out to all those post-acute care providers, train them on our portal, and get them to understand that there’s an engagement value here that says you have to answer referrals within 30 minutes. Seventy percent of Ensocare calls are outgoing as we are managing the network. That’s different from some of other solutions that just buy a CMS database, import it into their system, and call it done.

I build my database organically. Every time I do these outbound calls, I know which facilities aren’t responding. Our customer support people and customer experience people call them proactively to say, we notice that you aren’t responding to the referrals we’ve been sending you. Is there a problem? Many times it’s, oh, the lady that had the app on her phone left and we don’t know how to answer any more.

We deal with post-acute care facilities that are very technically advanced and are part of large national chains. But we also work with home care mom-and-pop organizations in rural parts of the country, so it can be challenging. But we actively engage and manage the network to make sure they are responding.

You wrote after HIMSS19 about how smart speakers like those powered by Alexa might be used in healthcare. What do you predict?

The interface is becoming more reliable. Nine times out of 10, Siri or Alexa gets it right. One of the biggest potential uses I see is managing the population after discharge. Once you get a risk score through LACE or some other technology, you know that this patient has two co-morbidities, is high risk, and has a lot of social determinants. The nurse wants to follow up, but they’re going to call you, ask you to enter information into a mobile device on an app. Many patients aren’t all that technology savvy. But if you send them home with a smart speaker, it could automatically populate population health platforms with vital signs. The nurse is now calling only the people who need intervention as opposed to calling everybody every day. That model is unsustainable.

I recently was at a hospital that had a warehouse full of 75 nurse navigators. All they do, all day long, is call people. I’m following up on your primary care visit. Did you pick up your prescriptions? Did you do these things? Tools like the smart speakers are going to begin to invade that space.

Do you have any final thoughts?

I worked for two large companies. Shared Medical Systems taught us how to be close to the customer. Siemens, true to its German engineering background, taught us all about process and engineering. A healthy combination of both of those things is appropriate.

But the one thing that can’t be supplanted, the one thing that you always have to keep at the top of your radar, is high-touch customer service. We have a person at the end of the phone each time. You don’t get routed and automated and have to press two and three to talk to a representative. We have a high-touch customer service that our customers appreciate.

HIStalk Interviews G. Cameron Deemer, President, DrFirst

April 1, 2019 Interviews 1 Comment

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

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Tell me about yourself and the company.

I’ve been president of DrFirst for about 14 years. DrFirst is primarily a technology platform company working in the medication management space. To de-jargonize that, we provide core technologies such as electronic prescribing, controlled substance prescribing, and a lot of things around medication history and interoperability. Those are often included in EHR platforms, hospital systems, HIEs, and pharmacies. We have a pretty broad footprint across the industry.

What is the best source for an accurate medication list other than asking the patient or their family members directly?

I would say DrFirst, of course. [laughs] Seriously, the medication history lists have come a long way. There has been a core medication history list provided by Surescripts for many years. We take that list and add medications to it from sources that aren’t providing their med history to Surescripts.

Getting a complete list is one issue. The other is making sure that the list is in a format that a hospital can intake into their own system. We do considerably massaging of the feed to make sure it has the right data elements. We clear up any discrepancies, such as around drug descriptions versus the NDC numbers and things like that. Then we help hospitals be ready to intake information from outside.

The best source is really a hospital or a physician that is using a very strong industry feed. It’s continuing to get better all the time.

It has always seemed hard to get old medications off the list, which could be done either by asking the patient if they’re still taking it or checking their refill records. Is that still a problem?

One of the things that’s exciting right now is being able to involve the patient more in that discussion. Medications they are no longer taking are one thing, but probably the more relevant issue these days is that patients are deciding how to medicate themselves. For example, it’s difficult to get a good, complete list of nutritional supplements that a patient might be taking.

But the other issue is that if I prescribe you a drug and you have some kind of reaction to it, maybe you decide that you’ll only take half a pill instead of a whole pill. Or maybe you discontinue it for a few days, you feel better, then you take it again and you feel bad again, so you discontinue it. Knowing how you’re dosing yourself versus how the therapy was prescribed to you needs to be addressed. We’ve been working on that primarily through more mobile interaction with patients, helping them understand how the doctor views their medication records and giving them a chance to update those appropriately for the physician.

I’m interested in your Link app, in which the patient receives a message under their doctor’s name listing the medication that was ordered, where their prescription was sent, and how much money they will owe as their co-pay. It even allows them to schedule a pick-up time with the pharmacy. Does offering a patient-facing application give DrFirst a way to grow in a new way?

It does. You and I talked about two years ago when we were starting beta testing of Link. We went into full-blown production with it within the last several months and have sent it to millions and millions of patients.

The way it works is that we know you’ve been to your physician, so we will reach out to you and try to make sure that you don’t abandon your prescription. We try to deal with what’s on your mind at that time. How much is it going to cost? What am I taking this for again?

A survey we did recently found that nearly half of all consumers aren’t sure they can take the medicine the way they were directed to take it because they can’t remember. The physicians usually are in kind of a hurry and the patient’s not thinking because they’ve just been diagnosed with some issue. Imagine that you were just diagnosed with diabetes or with high blood pressure and you’re not sure what that means. You’re not sure how you’re going to tell your spouse about it. You’re worried about how it will affect you physically. You may not be listening that carefully while the doctor is running through how you’re supposed to take your medicine.

We try to fill those gaps by reminding the patient. These are the meds that were prescribed. Here’s the pharmacy that has your prescription. Here’s some information about that therapy to remind you of the things your doctor told you. If you’re worried about how much it’s going to cost, here is the co-pay amount. Here is a financial assistance program, or maybe a consumer discount card if you don’t have insurance, which a lot of people don’t these days, or maybe they’re in a high-deductible plan. We take that cognitive load off the patient of not being able to remember what to do, being afraid of what they might have to do, and worrying about it. We ease them into starting their therapy.

I’ve always felt less empowered with e-prescribing. Before, I had a piece of paper that I could carry around to shop prices, I could get the prescription filled whenever I wanted, and I could research the drug before going to the pharmacy. Now I’m barely out of the doctor’s office when Walgreens starts the robocalls telling me to come pick up my prescription. Does Link re-empower the patient?

That’s an excellent observation. I actually feel the same way when I get a text message from the pharmacy telling me to come pick up a prescription. I may not have even been thinking about that at all. It’s just all happening in the background somewhere.

Another element of that is the rise of patient portals. On the one hand, it’s positive that we’ve been getting federal pressure for patient portals to be available in every EHR system, every hospital system. But it’s another way of taking some control away from the patient. Their data gets scattered between many electronic systems. It’s hard for them to bring it all together in one place. It’s hard to even just remember how to get to your portal a lot of times.

By going after the patient with this mobile solution only when they need it, we are trying to empower the patient to have all of their information in one place so they don’t have to remember what to do in order to get their questions answered. That’s probably the key here. As things become more electronic, there’s no reason that the patient should have a miserable experience of trying to navigate those electronic pathways.

Is the prescriber notified if the patient uses Link and decides for whatever reason to not pick up their prescription?

Not today, but we will have that shortly. We are incorporating a secure messaging channel from the patient back to the physician.

This is a new concept. Historically, physicians haven’t communicated with patients through text messaging, secure text, for a number of reasons. But that recent survey I mentioned found that an enormous number of patients, like 90 percent, said they would rather receive a text message from their doctor than a phone call, being steered to a portal, or being contacted via any the other methods they would normally get. We’re trying to meet patients where they are and give them the tools to be able to communicate something back to their physician in a manner that’s efficient for both the patient and the doctor.

This is a brave new world of trying to address what we call the care triangle. Think of a triangle with the physician on the top, a pharmacy at one corner, a hospital at the other corner, and the patient in the middle. Everybody needs to interact with and talk to the patient. But also, everybody at the corners needs to communicate back and forth with each other. We’re using secure collaboration tools to let all of those entities talk to each other in a real grassroots way so that we don’t have enterprise boundaries any more, or divisions between the medical professionals and the patients they serve. Letting everyone have the tools to be able to talk back and forth.

We hope that will be an important next step in making sure that all of the people who are working on behalf of a patient can synchronize and coordinate their care and to allow the patient to understand what’s happening and to be a part of it.

It would be interesting to put the patient instead of the provider at the center, with each patient having their own Facebook-like page in which all those messages and the patient’s replies are collected in one place that the patient themselves controls. Is that possible?

That’s actually what it is today. From a provider’s point of view, when they’re in our secure collaboration tool, they’re seeing one thread for a patient. It’s like text messages, with topics bouncing all over in the thread. In the collaboration tool, it’s centered around this patient that the care team is working on. From the patient’s point of view, everything comes into one queue where they can see a consistent record of the communications they have had.

What is the impact of an app that targets the patient specifically?

Link is quite powerful. We’re seeing close to 25 percent improvement in prescription abandonment just through Link. But we know that some patients, and particularly those who care for patients, need a more persistent experience.

But we also know at the same time that patients don’t care as much about their health as we would like them to. They don’t consistently focus on it in a productive way, which is why we forget where our portals are. We’re not in them all the time checking on things and sending messages back and forth. It might be because people don’t want to be defined by their illness. It might be that it’s just too psychologically heavy to continually think about your illness. But we tend to be concerned in spurts when we’re ready to pay attention.

A key focus for DrFirst is reaching the patient only at those times that they really care. During the times when they have less concern, we are just being available if they need us. We aren’t trying to get their attention during those times. We think that most patient applications fail because they assume the patient will be interested enough to continually interact with the application. We’re trying to put ours together in a way that addresses actual patient needs when they are occurring without requiring a lot of other activity otherwise.

What’s being done with opioid prescribing?

With all the pressure for physicians to use EPCS, it’s now about efficiency. Physicians not only are required to order the prescriptions electronically, but they also have to check the PDMPs, the state controlled substance registries. That is such a burden.

I saw my family physician recently and his office gave me three pieces of paper when I walked in. The first one said, you need to acknowledge that we don’t write controlled substance prescriptions out of this office. They made me sign that. The second one said, if I do write you a controlled substance prescription, I’m only going to write a three-day supply, and then you have to come back and see me again and pay for another office visit. I signed that. Then the third one said, the state of Arizona requires me to check the PDMP and they won’t pay me to do that and neither will your insurance company, so you have to pay me $15 for every controlled substance prescription I write for you. I had to sign that.

That’s happening all over the country. Doctors are pulling back from prescribing opioids because they don’t want to check the PDMPs. It’s too onerous. We’re starting to create a crisis of pain as opposed to a crisis of overdose.

To alleviate that, we’ve been putting a lot of effort into making electronic connections to every available state PDMP and then bringing the information into the physician’s workflow. Instead of leaving your EHR, authenticating into another system, entering patient demographics, and then going back to your system and typing the information in — because typically you’re not allowed to download it, you have to retype it — we make it so that right in the process of writing the script the opioid history is just right there, with no effort required. This addresses what unintentionally has became the next issue of patients — their doctors being unwilling to care for their pain at all as a rebound to the epidemic in the form of “let’s just not write them.”

It has been gratifying to see how enthusiastic physicians have been about making it this intuitive. It ought to be this simple and we’re we’re making it work that way for them.

Do you have any final thoughts?

We’re entering a time when there is so much pressure on the EMR community to continue to build features into their EMRs. We’re starting to lose the connection to the patient. The next big opportunity is getting all this information that impacts patient care in front of the patient at a time when they are ready to accept it and in a format that they can put to practical use as part of their therapy.

Patients for too long have been treated like miniature doctors who are laser-focused on their care. People don’t really work like that. I’m excited about digging in at the grassroots level to provide solutions to the real problems patients have trying to initiate and maintain their therapies over time.

HIStalk Interviews Grahame Grieve, FHIR Architect and Interoperability Consultant

Grahame Grieve is a principal with Health Intersections of Melbourne, Australia and was the architect-developer of HL7’s Fast Healthcare Interoperability Resources (FHIR, pronounced “fire”) specification that allows EHRs to exchange information.

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Was it weird to see FHIR as the only universal topic of HIMSS19?

Not so much weird. Obviously it was gratifying for us to see the community investment that so many people have made becoming justified. It’s definitely worth saying that we really value HIMSS’s active participation in driving the conference in that direction. There was an organicness to the fact that FHIR became the big issue given the way the industry overall is, but HIMSS definitely actively drove that and that was an important part of the picture. I thank Hal for pushing that.

I thought there was maturity at the HIMSS meeting this year. You and I talked about bad FHIR puns and expected to see them all over the place, but we didn’t actually see anything like that. We saw instead quite a lot of maturity around the discourse and the challenges of sharing data. I thought that was really good.

I always call you the father of FHIR without asking you if you accept that title. Is it fair or unfair to call you that?

I did initially draft it and propose it and I’ve curated the passionate community input over the years. If that makes someone the father, then I guess I am. The community is the real father. I get undue attention as if it was some magic that I achieved, where actually it’s just thousands of people passionately contributing to the common values that we hold.

I’ll repeat a question that I asked you last time we spoke. Are you worried that non-experts mistakenly believe that we’ve figured out interoperability because they keep hearing about FHIR and APIs?

That definitely happens. People assume that since FHIR is now the designated answer, it is the answer to all of the problems faced. But it’s not.

As HL7, we can only take on and mandate solutions that everybody completely agrees to. This is healthcare, so there’s a very limited set of things that everyone completely agrees to. Additional agreements are required. The scope and scale of the agreements required are beyond any single organization. We’re spending increasing amounts of our time investing in collaboration with other organizations to get a seamless process around scaling up agreements and consistency across multiple organizations like IHE that are helping out with the problem.

As long as hospitals buy an EHR and then spend a $100 million customizing it to their workflows, then interoperability is going to be a challenge. On the other hand, the fact that hospitals make those kinds of investments indicates the complexity of healthcare. There is no easy win. There is no easy victory to get interoperability with some kind of tick mark against it. It’s an ongoing process that we’ll be going through for a long time yet.

It seems like every EHR vendor has at least some customers exchanging information with the EHRs of other vendors and now CommonWell and Carequality are connected. Can product shortcomings still be given as an excuse for lack of interoperability?

The vendors work really hard, and from my perspective, the vendors are committed to making patient data as easy to move as possible. On the other hand, the vendors basically fight with their old legacy code bases that are extensively customized and very had to work with. That’s the nature of any mature software product. I think that if I was a consumer, I would be unhappy with where they are, rather than if I’m an engineer looking at their problem. It’s kind of a challenge for the vendors.

But increasingly, as I observe the space, the challenges are with the providers. To what degree do the providers want to share information? To what degree are the providers prepared to standardize their record-keeping practices and their clinical practices to make it easier to exchange data and to transfer patients seamlessly? Not many of the colleges really understand that problem. I would like to call out the American College of Obstetricians and Gynecologists, which understands the problem very well and has very standardized record-keeping practices on paper. That puts them in good stead to get interoperable.

A lot of doctors I talk to think about this as a technology problem, but it’s not a technology problem. It’s an information problem, and so technology can’t solve it. It needs clinicians to make clinical agreements in order to get clinical interoperability.

There’s one more thing I’ll say, which is that interoperability is not a binary thing. We get a degree of interoperability. We can routinely exchange patient summary information. But seamless transfer of care will require a deeper agreement. We’re not there yet. We’re working on those as a community. But I believe that increasingly the load will move away from the IT side or the technical side to the clinical side as time progresses.

Efficiently accepting patient information from an outside source requires placing it into the receiving clinician’s workflow and being willing to use information that was entered elsewhere. Not that we need another interoperability frontier, but is figuring those issues out the next one?

The trust issue is really important. I’m glad you brought it up, because increasingly as I look at projects around the world, the question, is who trusts who and why? A lot of the complaints I hear from patients about poor record-keeping actually comes down to no established trust framework. If the patient provides you with a written statement concerning their medical history and you read that, are you liable for not asking them verbally? Can you rely on that written statement? If you get a written statement from another institution, can you rely on that? The interplay between trust and liability is something that we’ll have to revisit as a community and make that a fundamental part of our interoperability considerations.

What could I do as Provider A if I find that I’m regularly receiving incorrect or unreliable patient information from Provider B?

Looking around the world, I routinely hear that more than half of patient records contain wrong information about the treatment history. Some of those are really, really wrong, and you can easily find examples of that in the media. Surveys that I’ve seen show that it’s more than half the records contains something wrong, and yet we make those available to the patient without any consideration for what a patient should do if they look at it and say, that’s not right, I’m a guy, so I don’t think that a pregnancy test was actually performed. Life’s a bit more complicated than that, but what do they do?

You asked the same question about providers with each other. There’s one organization working on the policies and technologies associated with this, which is Carin Health. But we should start moving towards a culture where it’s a professional obligation that if you share your records with somebody, you have an obligation to have some sort of error detection and correction process running so that your records can be corrected. But in today’s environment, we’re a long way away from thinking like that.

What has been the impact of Apple exchanging information with EHRs using FHIR?

There’s certainly discussion happening around Apple in particular, but more generally patient access to information and what kind of difference that will make. Obviously that was a subject of the keynote at HIMSS. Apple brings a particular sharpness to that debate because of its global consumer reach, the style of its consumer reach, and the potential for Apple to disrupt health in the way they’ve disrupted other industries. I certainly hear discussion about that. Some people are wildly in favor of any disruption. Other people are very much not in favor of any disruption. Some people are concerned about what a consumer company like Apple might do.

My perspective is that getting patients their data doesn’t really make much difference to patient satisfaction or behavior, because it’s all historical data. What makes a difference to a patient is the services that you provide. You need data to support the services, but it’s the services that matter. As long as healthcare services are fundamentally delivered in the flesh in the physical world, there’s a limited degree to which the consumer electronics companies can disrupt health.

In order to provide substantial healthcare services, you have to put people on the ground. That raises all of the classic “how do you manage healthcare” problems, for which I don’t think there’s any magic bullet. I think that their impact will be significant, but ultimately limited by real-world constraints.

Joe Biden and Seema Verma have recently expressed disgust that they, even as high-ranking government officials at the time, were unable to get the medical records of their relatives, and Verma in particular seems outraged. Do you think the government sees its role now differently than it did originally?

It has become more clear across the industry that what we have is not a technology problem. We have a business and an information problem. The government laid down a whole lot of money as far as stimulus, partly to spend money — which it did effectively — and partly to move past the technology barrier to the information barrier. Aneesh Chopra has told me that what happened was relatively predictable. We’ve now solved the technology problem. We can focus on the business and the information problems, and here we are doing that. The NPRM focuses on cleaning out the technology problems and moving the business and information problems to front and center.

But as the government, the levers that you can pull have limited effectiveness. That’s even true in autocratic countries. I was in one country where they showed me that certain things were happening in a particular way. The next day, I would meet with the programmers. They would say, “This is how we do it, but don’t tell the bosses, because they’re not allowed to know.” The levers that you can pull as a policymaker and a money-spender are a lot more limited than people believe. At least the US government is acutely aware of that, much more so than other governments I deal with.

Nothing leaps out at me as any quick solution here, so since the NPRM is marginal improvements being made over time, we can look for improvements. I’m particularly hopeful that we can solve the access to healthcare records problem through thoughtful change. I already saw that happen with vendors. When I started dealing with health information exchange, vendors were suspicious about exchanging patient data. They saw that as a business threat. Now when I deal with C-level people at the vendors, they’re all like, “Well, why wouldn’t we do that? We can’t not do that. It’s part of our business. It’s a business opportunity.” Whereas if I talk to providers, I see providers very much being, “Why would we do that? Why would we spend money doing that? Isn’t that a business threat?” It’s about making that same cultural adaptation to their thinking.

That’s the key thing that we need to chase — the understanding that exchanging patient data with the patients is a business opportunity, not a business threat. But it’s a cultural transition that needs to be bedded deeply through the provider before the provider is ready to see healthcare as a different kind of business model. There are a number of institutions around the USA that are pushing that as hard as they can. Hospital in the home, seeing the hospital as part of a wider network, the whole ACO thing is pushing that. There’s a bunch of things happening, so I’m not particularly pessimistic about it.

Does anybody still care about Blue Button?

There’s a really active community around the new Blue Button work that CMS is doing with FHIR. The FHIR community is picking up and processing the data. There certainly is interest in cross-correlating data from Blue Button with data from the Argonaut interfaces that patients can get, and creating a market in that space. The White House is interested in that. It makes a lot of sense to try and leverage some efficiencies out of the system by cross-correlating payment data and payment efficiency data with individual healthcare data.

That’s the logical place to look for where you, as a funder, could seek to provide more efficiencies in the healthcare system. In the end, the providers of healthcare are not motivated to perform systemic repair to healthcare. It’s the funders who are motivated to perform systemic repair. That’s an important part of the overall picture.

HIStalk Interviews Cedric Truss, DHA, Director Health Informatics Program, Georgia State University

March 18, 2019 Interviews No Comments

Cedric Truss, DHA, MSHI is director of the health informatics program and clinical assistant professor of Georgia State University of Atlanta, GA.

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Tell me about yourself and your program.

I’ve been at Georgia State since August 2017. We offer a bachelor’s of interdisciplinary studies and health informatics. With that program, we partner with the College of Business, so students take courses under the College of Business and within the College of Nursing and Health Professions.

A reader who ran across your students at HIMSS19 said they were engaged, asked great questions, and were enthusiastic. How would you describe their participation? What impressions were they left with?

I’ve gotten a lot of great feedback from some of the students. For some, it was their first time going, Some went last year in Las Vegas. They enjoyed both of the conferences. They said that they were able to connect with some of the companies and to talk with them about some of the things they have been learning in the program.

For instance, we talk about all of the EHR companies throughout the program, so students talked with individuals from Cerner, Epic, Athenahealth, and Allscripts. They were able to get feedback from those who are actually doing the work and to see how it applies to their learning in the program.

How do you cover the theoretical parts of informatics while also exposing students to the real-world aspects that they saw at HIMSS19?

We have a curriculum that’s set around the different areas of what encompasses health informatics. Throughout those different courses, we talk about the theory of why things are the way they are and how to actually make them work in practice.

We have a local Georgia HIMSS chapter and individuals come in to the program and talk to students in the different courses. They explain how what they are learning is applied. This past year we started doing something new. We’re participating in the academic organization affiliate program that HIMSS offers, so we provided all the students with memberships this year. This was the first time that we’ve done this and it is a success, so we will continue doing it.

Were students surprised at the size of the conference and the level of activity around the industry?

Yes, they were, especially for those for whom it was their first time going. I’m glad that it was in Orlando, because it was much closer. They came back and said, OK, now I know what I want to do, or I can pinpoint it. Being able to see this, I can decide what I really want to do and what I want to go into long term.

Yours is a professional program, where students are required to complete pre-requisites and then apply. What kind of applicants do you typically get?

We mainly get students who know they want to do healthcare, but they don’t want to deal with patient care or have hands-on patient care. That’s the majority of the students that we get. We’ve had some that were in the nursing program, and after seeing what they would have to do, they decided, “I don’t want to do this.” They come check out health informatics and fall in love with it.

We’ve also had a couple of students come from the business school. After looking at some of the CIS majors that they offer, they decide this is a better fit for them and the type of career they’re looking to go into.

What careers do they want to pursue?

A lot of students mention project management and analytics, whether it’s data analytics or performance analytics.

Many informatics programs target people who have earned clinical degrees. How does the science aspect of informatics fit with the caregiver side?

You’re not providing direct patient care, but you are providing patient care. You’re making sure systems are working properly so the caregiver or provider can provide you care. If it’s a nurse or a physician at Clinic A but you’re going to Clinic B, that provider can go into the system to see what you have had done, be able to provide the care that you need, and not do something that’s unnecessary, like maybe give you another vaccination that you’ve already gotten or diagnose you with something that you’ve already been diagnosed with.

You’ve worked in different parts of the industry. Is the academic setting different?

[laughs] It is completely different working in academia versus working in the industry. I did enjoy the industry. I loved it. I don’t get to participate as much now in the industry, but I’ve been able to develop new partnerships with those who are in the industry so I can create the pipelines for students to talk with those individuals who are practicing, do internships at these organizations, and even gain employment at these organizations after graduation. It’s been a great fit for me here in academia.

Is there a recognition among your students that Atlanta is such a stronghold of health IT?

There is. We have a lot of health IT companies here in the state of Georgia. Actually, Georgia is considered the health IT capital. A lot of the students are aware of what’s here and the many different opportunities that they can have. We have a lot of health IT startups here as well. That makes the area stand out quite a bit. It gives students an opportunity to say, if I go through this program and I have this idea, I can have my own startup here as well.

How do your students view their future work life differently than the generations that preceded them?

A lot of them are wanting to do different things. Some of them would like to develop their own business. Some of them are interested in traveling and consulting.

I have a master’s in health informatics, so when I went into that program, my idea was that I wanted to be a CIO. But once I got towards the end of that program, I decided that’s not what I wanted to do any more. The opportunities I have had expanded my knowledge and my interest in different areas. The students see what I’ve done and talking with them gives them an outlook that they can do many different things, whether it’s to start their own company, work for other organizations, or travel and be consultants.

Your doctoral dissertation was on hospital ransomware attacks. What are your takeaways from that?

A lot of hospitals were not focusing on security when they were implementing the EHR. I think they figured that they were covered since they had software and a vendor that potentially had them protected from all of that. But I think they need to take steps and have their own policies and procedures in place to prevent that from happening.

How could someone get involved to help your program?

They can go to healthinformatics.gsu.edu. There’s a lot of information on there and it has some contact information as well. Or if they want to reach out to me directly, ctruss@gsu.edu or 404.413.1222. They’re welcome to call me directly and we can discuss options.

HIStalk Interviews Mike Mardini, CEO, National Decision Support Company

March 13, 2019 Interviews 2 Comments

Mike Mardini is founder and CEO of National Decision Support Company of Madison, WI, which is part of Change Healthcare.

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Tell me about yourself and the company.

I’m a healthcare IT veteran. I’ve gone through three companies in the utilization management and documentation space. We were acquired by Change Healthcare about a year ago.

How will the acquisition change your business?

We had been working with McKesson for two years and they were acquired by Change. We had a good relationship. We knew what we were getting into when the conversation about them owning us started. We knew the people and we knew what the synergies were. We lived together before we got married. That was a big advantage, not only for us, but for them, too. It happened the right way.

It’s content integration and connectivity to impact care. To share data between providers and payers. A lot of assets come together.

How do you balance the big picture of growing the business, raising money, and considering who might acquire you or who you might acquire, all while you are still running the company day to day?

I’ve done it three times and I’ve asked myself that question. Each time was a little different. The first time was the first time. The second time, the strategic buyer was different. But it is a balance. You have to be true to the company and the company’s mission as opposed to a personal type of mission.

Some would say it was harder or easier for me since I never raised money. I never had a bank or a VC dictating what they wanted out of it. It was always personal. Whether it’s running the business or finding a partner, you’re in it every day. You have to be true to the mission of the company and to evaluate how the company is better off, whether it is run independently and we keep on going, or whether we’ve found the right partner to advance the mission. It becomes easy.

Change wasn’t the only one that wanted to us. From the day that we got started, I would say inside of a year, we were courted. We found the right partner.

CEOs have told me that instead of the champagne corks flying once the deal was done, the due diligence was like a colonoscopy and then it was second guessing about whether it really is the right partner, the right price, and the right thing for the company and its employees. Is it hard to balance the negatives and positives of multiple offers?

It was a lot easier this time around than the other two times, whether it was experience or that we had been working with them for two years. It is difficult. It is the colonoscopy. It’s all of that. But this time around was a lot smoother. We knew what to expect, we knew the people, and everybody’s heads and hearts were in the right place.

How hard would it be for a health system to set up and maintain ordering appropriateness checks on their own?

It’s a huge project. They all have a few dozen alerts and advisories. When we install our imaging product, it’s 15,000. Maintaining and managing with native EHR tools is a huge task. That’s why they only do dozens. All the content is managed locally.

Governance is an issue. Tracking the impact and the effects. It is a huge undertaking for sites to do it alone. I’m not sure they even realize how big the problem is. But as the market starts to evolve, they’re starting to ask all the right questions. We want an enterprise partner. We want to understand your analytics. We want to understand all the components, not just whether you put this alert in my EMR.

How do doctors react to that extra level of review or entry that is required to ensure clinical appropriateness?

The docs who are complaining about alert fatigue are primarily correct. When you install your EMR, you have people putting all these alerts. There’s not a lot of thought that goes into it, and even if there is on the front end, there’s not a lot of thought on an ongoing basis. They’ll add five alerts, then two years later, they add another five without taking a look at the original five. A doc does something in the EMR and three boxes pop up with kind of related, yet unrelated alerts. All they do is X through it. There’s no response, there’s no impact, it’s just these things that pop up and they pop up all the time. Nobody says anything, because they’re just X-ing through it.

Thoughtful implementation of guidelines to where they really have an impact, and putting them in place where we’re using the data from the EMR to fire guidance when it’s appropriate. When the end user connects, you understand what the value of it is.

That being said, we still see see doctors who don’t want to see them because they don’t want to see the EMR. They don’t even want to work inside the EMR. There needs to be an improvement in the thought process and the implementation of these advisories to ensure that they’re optimized so we’re not wasting people’s time.

The “revenge of the ancillaries” must play a part, where anyone in any department who wants to collect more information or make their own job easier dumps a new documentation requirement into the newly installed EHR. Is it easier to sell the idea that your recommendations were created by the societies to which those physicians belong?

It all depends on the use case. Sometimes the information is from societies. Sometimes it’s a local rule that a facility wants to implement. Sometimes it’s a payer rule. We try hard to make sure that the guidelines that are actually put in are relevant and respected by the end users.

Imaging is particularly hard. We took on the absolute hardest part of it. An entire service, in some cases 3,000 orderables, 7,000 clinical reasons for why you would want to use those 3,000 orderables, as well as variants used by every specialty in healthcare. It’s not something like, let’s put an alert in there for blood management if the patient’s hemoglobin level is above seven. Everything that we do beyond imaging is much easier for us to hit the target.

Why does CMS keep pushing out the mandatory date for implementing advanced imaging appropriateness rules?

This next date is set in stone, short of a big lightning strike. But I think the market is constantly making CMS aware of just how huge this implementation is. Everybody orders imaging, so they are communicating to CMS that it’s going to impact everybody. They’re getting a lot of push-back. They’re getting a lot of blowback from the market. They want to get it right.

It’s not just that they pushed it back, they have refined it, too. It is not all imaging, it’s certain clinical scenarios. But beyond just that, it’s figuring out how the data gets on the claim forms. There’s a whole process, not just on the provider’s interaction with CMS, but how all this data is going to flow and how they’re going to keep track of it all.

Do I think that they could and should have gotten this done faster? Yes. Am I surprised that it has taken this long? No.

Hospitals get paid well for imaging that best practices say it is inappropriate. Are they interested in ensuring the appropriateness of imaging until CMS forces them to?

That is almost the norm. They want to use it for the stuff that they’re at risk for, but they’re not as excited about it for the stuff that they’re not at risk for. We have seen that.

But the market is moving in a different direction. As the risk shifts to providers, this concept of a standard of care and making sure that there is no waste becomes tantamount. Not just to patient care, but to profit as well. As the risk shifts, everything looks like a DRG. Everything looks like a bundle. We are starting to definitely see a shift in wanting to adopt more and more as this risk shifts. They start acting like payers.

How is Choosing Wisely, which is endorsed by Consumer Reports, being implemented and what results are we seeing?

It’s another set of criteria. Some of it is really good. Some of it is impacted by evidence. The single greatest thing that Choosing Wisely did was create a market awareness that it’s workable to put guidelines in place to impact decision-making. It’s possible and it should be put into place. It has created an awareness.

Many of the Choosing Wisely guidelines are obvious. There’s no debate on them. So it has done a great job of creating an environment where the market is willing to accept putting guidelines in work flow to impact decision-making. The guidelines themselves are good, some better than others, but the awareness that it created is the impact that it has had.

What causes the gap between what a competent practitioner wants to order versus an insurer or hospital that thinks they need to tell them they might be wrong?

There is new data out there that docs may or may not be aware of. The average CME credits that docs get every year can’t begin to cover and keep docs updated with the latest knowledge. One of the points of implementing an EMR is to solve this gap in data. This ability to shed a light to docs on data that is available that would help them in their decision-making. I don’t think anybody could reasonably argue that doctors can’t benefit by being made aware at clinically relevant times that guidelines out there are proven or should be followed. It’s not for every case, but this is science, and information is being found all the time.

We talked about how risk shifts. Let’s go to the extreme and say you have a full-risk model on a provider’s side. Now, when a third part is paying, it’s the third party’s money and they are trying to save on unnecessary testing. Once the risk shifts to the provider, the issue is reversed. How do we prevent the provider from cutting corners? How do we prevent the provider from doing things to save money? It’s not based on bad things or evil or greed. It’s about keeping the lights on.

The only thing that protects providers from liability around cutting corners is to reduce variation in care, to establish a standard set of “this is what we do in this clinical scenario.” It doesn’t mean that somebody can’t veer off of it if there is a variant that exists. But it’s a standard that everybody follows. That ultimately will have to happen to give the provider not only protection from liability, but credibility. Why should the same type of patient with the same scenario walk in and get two different protocols?

Do you have any final thoughts?

I want to go back to the synergies with Change Healthcare and what we’re actually doing here. NDSC came to the table with a content management solution that is designed to deliver provider-focused guidelines seamlessly integrated into EMRs. In a standard way, extract data, calculate that data against guidelines, and then send that clinical data wherever it needs to be sent. We have a large provider footprint and success in the market. Change brings a host of criteria through its InterQual asset, a dominant product in the market that is used by health plans. They also have advanced business intelligence, a large investment in AI and machine learning labs, and a very large network of payer connections with a whole host of claims information.

We are working together to close the loop on delivering guidelines into the physician workflow, then being able to share that information with payers or whoever is financially risk to insure that the right things are done and to mitigate waste.

HIStalk Interviews Guillaume de Zwirek, CEO, Well Health

March 11, 2019 Interviews No Comments

Guillaume de Zwirek is founder and CEO of Well Health of Santa Barbara, CA.

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Tell me about yourself and the company.

I founded Well almost precisely four years ago. My background is not in healthcare. I started my career as a classical musician. Then I worked at Google for four years, then afterward at a big data company that we sold to Amazon. I started a healthcare company because I found myself in a hospital one day and I was just so frustrated with my experience.

Well helps patients and administrators break free of antiquated communication practices. We provide a single command center that connects the many tools they use, transforming everyday interactions between patients and providers.

How can we be sure that hospitals will think about what the patient needs and wants instead of just blasting out self-serving, generic messages that focus on whatever benefits the health system’s bottom line?

I founded this company because I was disturbed by the amount of robo-spam that existed in healthcare. When I was at Google, I saw a transformation from web to mobile apps and then from mobile apps to messaging. That was happening right around the time I was leaving. 

My experience in healthcare in 2015 was precisely what you are describing. Getting four to 17 messages, all saying the same thing that I can’t respond to, with no human on the other end. My only recourse is to call and wait on hold for 17 minutes. That to me is not customer service.

This is an industry that takes up the vast majority of GDP. On average, Americans spend $11,000 a year on their healthcare. A lot of that goes to insurance companies, but you would expect a bare minimum level of support in that environment. One thing I love to tell my team is, pick your favorite retailer — Nordstrom, Lululemon, you name it. Imagine if they were guaranteed $11,000 for every customer that walked in their door. What would they do? How would they treat their customer?

That’s how I like to think about healthcare, because I’m not from this industry. This is my first time in this industry. I encourage healthcare systems to think bigger and to go beyond the status quo. In an era where everyone is talking about AI, machine learning, and automation, we’ve gone in with a totally different approach. You have a phenomenal staff of people at your health system today. They just need the tools to be able to speak to your customers more effectively and make them feel human. It’s really concierge care, but in a way that is much more efficient for both parties involved.

My experience is that providers like to put up self-serving technology walls as a scalable alternative to paying humans to be available, so that if they can make money sending out robo appointment reminders to the potentially unruly masses without hiring people, that’s all they will do. How do you sell them on the idea that it’s OK to allow customers to speak with an actual human?

The problem is that the tools and techniques that are being used today aren’t effective. Look at the portal’s adoption rate across the industry. It’s abysmal. Ask every leading healthcare IT company about their numbers and what engagement looks like with patients. It’s not pretty.

When I was working at Google, my success and failure metric was, will a billion people use this? I was thinking about things on a different scale. I would have gotten fired for having 10 percent of people engaging with a release that I made. That to me is the framework that healthcare should be thinking about when they’re thinking about technology. 

The reality is that you’re only going to engage people when you treat them the way they want to be treated. For texting especially and for messaging, I was seeing a very disturbing pattern. I didn’t want texting to become the new email.

For me, that meant putting humans behind the scenes. An even more important piece was connecting all the pieces. I’m going to divert from your question a little bit, but I’d like to speak to a trend that happened 15 years ago with the EMR and the EHR. This concept where health systems had bought a lot of best-of-breed technologies and all the data was sitting in different silos. The EMR comes around and all the data comes together in one place. Obviously the government fueled this, but there was a deliberate effort by health systems to piece everything together into a central database. Epic and a bunch of others did a great job here.

When I talk to health system executives, I give the same pitch for communications. We’re in a period in time where customer loyalty, customer retention, and building a long-term relationship with patients are critically important. You will never be able to do that if you have 100, 200, 500 different healthcare IT vendors that are all trying to communicate with your patient independently.

I was talking to a health system executive three weeks ago who told me she has 1,000 vendors. One thousand. She did a journey map of her patients, and there was a situation where a patient can get 17 appointment reminders coming from different systems. That’s because the systems aren’t playing nice together.

A big part of this is the educational piece. My pitch to health systems execs is think about communications the same way you thought about data 10 or 15 years ago. Everything needs to be routed centrally. You need to have live agents on the other side to help patients when there’s a need for service recovery.

Health systems like the idea of patient engagement even if they don’t fully understand or embrace what it means. Are they talking to patients about what they want and how they want to receive it?

I’m encouraged by the fact that over the past few years, this position of chief patient experience officer or patient access has become pretty prevalent across health systems. I’m encouraged by the fact that health systems are hiring leaders from outside of healthcare.

Product design and customer research in healthcare is probably lagging behind other industries. A lot of that has to do with the fact that healthcare has acted a lot like a monopoly over time. It’s hyper-local. There might be only a few health systems. The insurance companies control the patients, where you go wherever your insurance company pays. A lot that is changing as patients pay more money out of pocket.

But healthcare for the longest time has had the makeup of a monopoly, just like cable companies and the government. Which is why when you look at customer service ranked by every industry, those are the three worst. They all have monopolistic tendencies.

As someone coming into healthcare from the outside, did it surprise you that unlike in nearly all other industries,  we can’t really define who our customer is?

I’m fortunate that I wasn’t from healthcare and came to the industry with open eyes. I’ve learned a lot. Healthcare is complicated, and for good reasons. There are nuances with patients. A mother with three chronic conditions in a rural area is going be very different than a high-tech Silicon Valley yuppie. There’s a lot of merit to healthcare being more complicated. It is a really, really hard challenge. 

We’re still in the early days of figuring out what a patient engagement strategy means. Health systems are thinking through individual problems. Let me tackle scheduling and registration, eligibility, or telemedicine. We should be taking a step back and thinking about how we can help patients of all these different backgrounds navigate their unique patient journeys. That’s where it comes back to communications for me. That’s where I’ve been laser focused over the past four years.

Is it difficult to get that rational argument heard above all the noise that tends to buzz around healthcare IT?

That’s one part of it that is sad. The most effective way we’ve found to sell is come in and rip and replace legacy systems, the robo-dialers and robo-spammers that every health system has today that send out those appointment reminders that patients love to hate. Then, hopefully, to use that as our Trojan horse to start developing a strategic relationship with the executives and help them understand how they can map out the end-to-end journey, put agents behind this, and offer an unparalleled experience. But that’s the hard part. It’s unfortunate that that’s the way in.

But I’m also pragmatic. I realize that this is a complicated industry with a lot of competing initiatives. Every health system is doing a double Epic upgrade and and CMS is changing their rules left and right. I understand the nuances and the complexities. It was definitely a surprise for me, and one of the sadder things for me, that we have to start there and I can’t start with the full package. I can’t start by implementing this comprehensive, end-to-end solution that would change the way patients experience healthcare. 

It’s baby steps. The jury is out over the next two to three years whether we can get people from that better robo-dialer experience to a truly integrated communications journey for patients.

In the absence of a chief experience officer or chief patient officer, who makes your case internally?

It depends on the health system and where the pain is felt the most. Sometimes it’s IT that is so frustrated with the way that their systems run today. In our world, it’s batch files at night that sometimes go wrong. Patients get the wrong messages and they end up filing support tickets and waiting three weeks. That is when IT feels a lot of pain.

Sometimes it is operations. You’ve acquired health systems, brought on new doctors, exited doctors, and you’re having to manage this entire operational side that is just becoming too time-intensive with existing technologies. That is typically where we are selling.

What is more interesting to me as we move towards risk is thinking about how we could potentially sell on the financial side, to the CFO, to the CMO, to the CNIO. People who realize that keeping patients out of the ED, keeping patients healthy, keeping patients adhering to the protocols that they want them to has long-term impact on their bottom line. That’s where I’d like to see things go. The message will resonate more. But we are still trying to figure out how to sell our message to that group.

How should a startup work with an accelerator or incubator?

You have to go in with a clear goal and objective. We went through an accelerator that was done in partnership with Techstars and Cedar-Sinai. When we accepted the offer to join that accelerator, our goal was to rip and replace their legacy reminder vendor. That was my only goal, my team’s only goal, for the four months that we were there.

We knew that if we succeeded, it would have been worth every minute we spent there. If we failed, we would have learned a lot about how to sell into healthcare, large health systems, and the nuances of workflow. We were successful, but even if we hadn’t been and we had learned those lessons, it would have been time well spent and we wouldn’t have been stuck in this endless pilot phase. I recommend not doing free pilots.

When it comes to accelerators with health systems, I’ve been disappointed to see some of the new accelerators that have come out that try to charge startups money to join. It’s so hard to start a company and be an entrepreneur, especially a first-time entrepreneur like myself, and if we’re going to encourage innovation in healthcare, we need to encourage companies to come to our health systems and spend time with us. We should pay startups if we can. If we want a pilot of their technology, we should pay them, because it costs a startup money to get something running.

The most important thing is that they learn, and they learn quickly, is that the killer of all innovation is time. You can’t buy time. You can’t make time. You have to move as quickly as possible.

We say in health system IT that nobody in the organization is empowered to say yes, but everyone is empowered to say no. Do you find that you need someone to go to bat for you?

It is better to get a quick no than a maybe. I learned this in raising venture capital money. I’ve raised over $14 million and I learned this lesson the hard way many many times. It is way, way better to get a no than it is to wait for months and months and months for a maybe.

The way we did it specifically when we went through the accelerator is that I just asked for meetings. I had a list of 56 practice administrators who had some sort of decision-making authority over the system they had in place. People are normally happy to introduce you to other individuals, especially entrepreneurs and people who are trying to introduce innovative technology. I went into those 56 meetings with an open mind, but a very very clear goal. I got great feedback and refined my pitch, and at the end of the day, I had 50 people who said, I would pay you for this. 

I went to the CIO of this health system and said, I’ve got a bunch of contracts. I think you owe me a few million dollars. What do you think? And I got three pilots out of that. They paid me for the pilots, which was fantastic. But getting to no is sometimes a much harder feat than getting to yes, and it’s just as important.

Silicon Valley types often think they know everything and roll their eyes at any industry that they think is not using technology optimally. How did you develop an ability to avoid talking down to healthcare people in a way that would have made them less likely to want to work with you?

I had my foot in my mouth a few months into starting this company. I was trying to get into this accelerator and they thought we were blowing smoke around integration. I had never integrated before. It sounded really easy. I talked a really strong game around integration. They gave me a second chance to come in and have some humility, be honest about what we knew and what we didn’t know, and where we needed help. I’ve carried that lesson with me every single day since that experience, and that was almost three years ago.

At the core, what keeps me honest is that I’m a patient. All I want is to make things better. I want going to the doctor to be as easy as meeting up with a friend for coffee. I recognize that there is way more complexity than patients ever realize. If I can seek to understand that complexity and partner with health systems to figure out the right solution to making that seam invisible and frictionless to patients, then that’s a win. It doesn’t matter how long it takes. I just need to find the right partners who are willing to get creative and co-develop with us.

That’s where I’m having some of the most fun. Learning with health systems, understanding the challenges, getting curious, and at the end of the day, just trying to make the experience of healthcare something that’s as enjoyable as calling an Uber.

What are the most relevant lessons you learned while working for Google?

There are two lessons that came from the company after Google. I was at a company called Graphiq that now powers a lot of the technology behind Amazon Alexa. The founder there is Kevin O’Connor, a serial entrepreneur. He founded a company called DoubleClick that runs most of the display advertisements on the Internet. 

I learned two concepts from him that I’ve carried with the company. The first is the concept of test-fail-learn, test-fail-learn, test-fail-learn, test-succeed, and then scale the crap out of the things that work. We do a lot of testing. We are very, very focused on analytics. We want data from our customers. We want to give them the data we have. When things aren’t working, we want to pivot.

I’ll give you an example. Early on, we thought that we could launch a health system-to-patient communication solution and also launch a clinician messaging solution at the same time. We failed miserably. I realized within two days of launching a solution that that was such a hard and complicated problem that there needs to be companies dedicated to that solution. Companies like Vocera and TigerConnect do that. That’s just one example of me learning and the test-fail-learn, test-fail-learn mantra.

The other one is this concept of scalable opportunities. Looking at the market, thinking about the things that really excite us but that we don’t really know how to solve yet, and assigning people to those initiatives just so that they become experts in them. As we figure out ways that we might be able to plug into these trends, testing solutions. For us, those are things like the payer landscape and value-based care. There are seven other items that sit on our whiteboard that no one’s actively working on, but we have one person on the team dedicated to thinking about them. One day they might find their way into our product and into our solution. But they are very much pie-in-the-sky ideas, scalable opportunities that we might choose to introduce to our company one day.

As a healthcare newcomer, what did you think of the HIMSS conference?

There was a lot going on. My heart goes out to anybody making purchasing decisions in healthcare. There are so many choices, there is so much noise, there is a lot to make sense of. In my opinion, it doesn’t look like there are clear winners in any category. Walking the, whatever it is, one mile or two miles of the exhibit floor is a clear example of that.

We knew that we had to have a decent presence at HIMSS for people to take us seriously. We went to HIMSS with two goals, to build vendor relationships and to meet with our existing clients and to meet with prospective clients while they’re all under one roof. I was happy with our performance and being able to achieve those goals, but it is a noisy space. I don’t have any solutions around how to make sense of the noise. I guess as a vendor, trying to be louder and trying to prove more value in a way that people hear who are making those buying decisions.

Do you have any final thoughts?

I’m having more fun than I have ever had in my career, and I’m 12 years into my career. I’m sure you’ve heard this from people many times in the years you’ve been writing HIStalk, but I believe that we are at a juncture in healthcare. I believe that patients feel empowered. I am encouraged by many of the new companies coming into healthcare. I am so encouraged by health systems that are opening up their doors to companies like ours, to help them learn and to help them bring new technologies to market. I am hopeful that investors will continue putting money into healthcare IT and that they will see big successes that keep fueling development in healthcare. 

At the end of the day, my personal goal is to flip the status quo, in which healthcare is in the bottom three industries in terms of customer service. In my humble opinion, it should be number one.

We have a long journey ahead, but there’s a lot to be encouraged by and excited about. It’s people like you, investors, health systems, and frankly, companies coming into the space and even competitors of ours. So I really thank you for taking the time to speak with me and for seeking me out. It’s people like you who are helping drive this industry forward the ways it needs to be driven forward. I’m very appreciative.

HIStalk Interviews Randall, An Anonymous Health System CIO

March 6, 2019 Interviews 4 Comments

I invited health system CIOs to interview with me anonymously, knowing from unfortunate personal experience that health systems don’t like their executives going off script to a national audience. Randall (not the interviewee’s real name) offered to spend 20 minutes on the phone with me to talk about what it’s like on the front lines. CIOs willing to do the same can contact me to arrange a fun conversation.

What are the hardest parts of being a health system CIO?

You serve many masters. The administrative area — the CEO, CFO, CMO — each have different objectives, goals, areas of influence, and levels of influence. Then you have your physician population, both from the acute care setting and employed physicians in the clinics. You have the masters of the regulators and dealing with the Promoting Interoperability Program at both the federal and the state level. You have operations, the directors and managers who are dealing with patient care or the revenue cycle or finances for the hospital. You also have another group to deal with in vendors and contractors.

At the end of that, you have your staff. You have a workforce that’s dealing with the same types of pressures you are at the CIO level, but they get it day-to-day in the field. You have to encourage them, empower them, and coach them to deal with that environment. That takes a very special set of people with their goals and their work ethic aligned with the organization to keep them going. Otherwise, they’re looking at it as just an IT job. They probably won’t survive in the healthcare space very long.

It’s a challenge and it’s a lot of juggling, but I chose this industry because it is challenging. It changes and requires you to think on your feet, to plan, and be strategic. It is not a boring job, that’s for sure. It can be frustrating at times, but it can also be very rewarding. You go through these challenges with people who you spend quite a few hours with, do a lifetime of work with, and you can identify with each other on each other’s challenges. You build some pretty strong relationships.

At the executive table, how do you reconcile what everybody wants in making sure that IT’s contribution fits into the overall health system strategy?

That’s the unique position that we are in as IT. We are exposed to all the workflows, especially on the applications side. We know the upstream and downstream effects that changes have. We know the benefits of using a technology, but we also know the downfalls of not planning it out well.

Those around the leadership table have a difficult time. They have to consider the mission and strategic plan while compromising around a single goal of achieving that strategy, but they have their own needs in their departments or with a particular physician.

We talk about flexibility all the time. But we have to set a course and not just stay the course. We have to support each other through those difficult decisions, what might be great things to do that would detract from what we already agreed are our priorities.

In each senior leadership team meeting, I say, here are all the things we’ve committed to. Here are the estimated hours the IT team alone needs. But we’ve already committed more hours than are available over the next six months. Then the CEO starts to look down the list of projects to ask for each one, why are we doing this?

When they start to dig into the projects, they circumvent the original decisions that were made by the VPs to execute on those projects. They are looking to the CIO to say what the priority should be. The other side of that sword is that two years ago, there wasn’t much governance going on in this organization. Senior leadership and directors were complaining, “IT is telling us what to do.”

OK, which is it? Do you want us to provide the guidance or do you want us to just facilitate it? That’s a challenge. There’s a balance there. This particular organization is having a lot of struggles getting into a more formalized initiative and governance process around their projects — not just in IT — and understanding what resources are involved with those. When they make changes, what impact does that have on projects that have already started?

Are executives worried about high software maintenance costs?

I don’t necessarily see that as an issue here. We cover that pretty well during the budgeting process for capital stuff. Maintenance is budgeted. It is a big nut, a large number. The board sees the percentage of operating expense coming from the IT area on things like maintenance continuing to climb, so they are aware of it.

The bigger challenge for this organization on its maturity curve is that when they look at a solution and they’re working with a vendor, it tends to be siloed around just the solution. What about the upstream effects or needs for your system and the downstream effects?

I’ll give you an example. We have a rather old cardiology rehab system that is documenting patient care. It needs to be replaced because it is no longer supported, but they want to interface that information into the main hospital system. But what they submitted for consideration was just the software and the maintenance for just that piece of software. Nothing about the IT hours needed for integration and the cost for the other system to do the integration.

IT ends up becoming the bearer of bad news on every single project for unplanned cost. It’s not just maintenance, but presenting the entire package of everything that’s involved with a particular initiative so that we don’t have any surprises.

Unfortunately, we’re still having surprises. Vendors don’t want to share that information. The sales folks want to close that deal as quick as they can, The standard feedback from them is, “You won’t need any IT support.”

What is good and the bad about having a few limelight-seeking CIOs representing those who just stay home and get their employer’s work done?

The good is that they sometimes expose you to other things that are available. The bad is that they represent themselves as the experts based on experience and most of them don’t have the experience. They are out there interacting with vendors and other industry people who have a particular agenda to address. Rarely have those who are popping up all the time been involved in implementations and dealing with the interactions with the physicians and the staff, both their own staff and the staff in the hospital. They are ego stroking. Hey, look what I know.

For me, it doesn’t necessarily translate into experience, lessons learned, and how I might be able to do that in my particular environment at a community hospital or a large health system. Other CIOs have actually been in the field, but they are few and far between and also in high demand.

I liken them to the chief medical officers that have grown up through an organization. They have a difficult time balancing the days that they’re in the clinic and treating patients with all their administrative responsibilities of the medical staff and administration. It’s a tough job. I always appreciate when those kinds of individuals who have real-world experience are willing to share that information.

The guys that are out there on LinkedIn and all the publications out there, telling you that “this is what you should be doing,” I have to take that with a grain of salt. It’s great to hear about what things are available out there, but sometimes they have to bring it back to bit of reality and what hospitals can actually do.

What kind of information sharing is most effective for a CIO who has to work for a living and who doesn’t have unlimited budget or time to self-promote?

CHIME has been a pretty good forum for CIOs to share information, although I’m starting so see it morph a little bit towards what HIMSS has become. I’m hoping they hold the line and don’t go that far. Those interactions between CIOs, one on one and sometimes in smaller groups, tend to be most valuable to me.

Every once in a while, I will reach out on the MyCHIME bulletin board to explain something I’m trying to solve and ask, has anybody gone through this? Some people like to share what they have done and what they have been challenged with, but not in an open and public environment out there like a magazine or something like that.

Is it too late for HIMSS to reel in vendors and is CHIME is too far along the path to do the same? Or is there no inherent conflict between what vendors want and what provider members want?

That’s the hard part. I don’t know that I have a solution for that. Vendor involvement is somewhat of a necessarily evil. Their motivation, no matter what they say, is that they have a business to run. They have to grow. They have to generate sales. They may have a great product, their company may have started off with a great idea and just grew from there, but in the end, they have to generate more leads. That’s the nature of our economic engine.

I find it a really difficult job for HIMSS to do. But at this year’s HIMSS, I was actually a little bit pleasantly surprised by the education sessions that I went to. Vendors weren’t running those presentations like they did in the previous couple of years. It was a little bit more low key with the vendors this year.

CHIME does a pretty good job of asking vendors to establish relationships with CIOs rather than coming in and doing hard sales. They do that through their focus groups, which is a pretty good idea, having five or 10 CIOs or senior IT leaders talking with a vendor about what their future plans are and what problem they are trying to solve.

I’ve been to a few focus groups that involved a solution looking for a problem. But in those focus groups, the CIOs are emboldened by each other being in that room and helping each other out. They give the vendor feedback and sometimes tell them straight up, this isn’t a problem we’re trying to solve. Or they’ll tell them, this is a great idea, but have you thought about it in this area? Trying to tweak or mold their solutions to that particular problem.

A good example from CHIME is that a year or two ago, I was on a focus group with the IBM Watson people. The entire room kept saying, what are you really delivering here? IBM Watson basically ignored all the feedback, at least based on the public perception that’s out there now. They still haven’t delivered. It’s a great idea in terms of what it might hold in the future, but overhyping on the front end doesn’t really help them. It destroys your reputation when you can’t deliver.

Health systems claim to embrace innovation, consumerism, and value-based care, but they still use fax machines, offer a poor visitor experience, and make a fortune by cranking out fee-for-service work. Is there a difference in what hospitals say versus what they are motivated to do?

Value-based care is BS. You are talking about trying to get to a subscription model with a patient. If your clients, your patients don’t want that and don’t feel a need to do it, then you are forcing a business model on them that won’t work. They don’t want it. They don’t feel the need for it. They just expect delivery of high-quality care episodically when they are ready and they need it. I don’t know that a hospital can solve that problem.

Hospitals and clinics can become more consumer-centric. As an administrator or an IT person, when you go to a clinic or hospital, what do you expect as a patient to be delivered that you might get from other types of industries? You would like to be able to do things on your smartphone. You’d like to be able to schedule appointments online. You’d like to be able to get your medical records freely and easily.

We have to back away from the regulatory demands and the billing demands and get on the front end of the consumer. Because in our environment, in our US of A, everything is based on capitalism, and he who builds the better mouse trap is going to draw more customers.

I don’t know how we will ever make that transition to value-based care unless you have a single-payer system, which I’m not an advocate of. But I don’t know how else you can do that. You are forcing patients into having to become subscribers to a healthcare service rather than episodic paying for what I need, when I need it. That’s my opinion, but the current environment pays my paycheck and I have to operate within it.

HIStalk Interviews Michael Schmidt, Managing Director of Strategic Innovations, Orlando Health

March 4, 2019 Interviews No Comments

Michael Schmidt, MBA is managing director of strategic innovations at Orlando Health’s Strategic Innovations program in Orlando, FL.

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Tell me about yourself and the organization.

I’m the managing director of Orlando Health’s Strategic Innovations program. My responsibility is to coordinate our internal and external innovation efforts.

My colleague Callie Patel from Healthbox and I just presented at HIMSS19 on developing internal innovation competencies. We did a case study of Orlando Health’s journey over the past two years in going from having no formal innovation program – no structure, resources, or any of that — to having a formalized program where we run an annual internal incubator. We have various pathways for different types of projects. Then we have a venture fund to invest in external healthcare startups that align with what we’re trying to do.

Many health systems are experimenting with incubators, accelerators, and innovation funds. What are they trying to get out of that, and what have we learned so far?

There was a quote that was a theme during HIMSS that if you’ve seen one innovation center and program, you’ve seen one innovation center and program. Everybody’s trying to tackle similar concepts and strategies, but the execution looks pretty different. The more I’ve started scan the horizon and look at other health systems, I’ve been surprised how many have a program like this. Maybe not the same setup or focus on internal and external at the same time, but most of the major health systems in the country have moved in this direction somehow.

We might be a little different. First and foremost, our goal with an innovation program is culture change. We’re a $3.2 billion community health system across central Florida and operate at a very effective level, but we have never had a lot of the core competencies that a university hospital system or big hospital system in a large metro area might have. We’re playing catch-up a little bit.

We realized that a lot of what we needed to accomplish was education and acclimation for a lot of our physicians and team members to understand what innovation means to us and why we’re doing what we’re trying to do. Then, how they can play an effective role in that. Secondary to that for now is the ROI on the initiatives. Over time, that will change, but we’ve been trying to focus on engagement with our employees and our physicians.

I credit our partner Healthbox for their structure and their philosophy. Technically they’re a consulting group, but they’ve partnered with us. It’s almost like I added 10 to 12 people to my team from Day One in working with them. We’ve set up a consistent process, a thought structure and philosophy on what types of ideas we are looking for, and the criteria we used to assess those and to decide which ideas advance.

For our internal incubator, which we call the Foundry, we only accept four ideas each year. We would rather have a small number of successful projects than dozens that are stalled out in some different phase of development. We ask our team members and physicians to look for ideas that solve pain points that they’re experiencing. We have criteria that we assess these ideas on. Throughout the entire fall, the application window is open for people to submit their ideas, providing rationale as to what impact it will have internally. Will it save us money, help us consolidate the supply chain, or improve quality?

We look at five facets of that application and score the idea and the innovator across these things. What is the commercial potential? Is this idea eventually going to fit in a market that’s super competitive, or is there a decent-sized niche that we could carve out based on how unique this idea is? How innovative is the idea? Is it a small iteration on an existing idea or product, or is this big-shift, game changer, completely new type of product or service?

We also look at the person who brought the idea forward. Not everybody has the same natural entrepreneurial skills, so part of what we assess is what type of support structure, education, and team we will need for this person to be able to drive their idea forward.

Finally, we look at the potential internal impact and how it aligns with our strategic plan and the pillars of that plan.

We score everything across those five categories. We rank them, and then I have a committee of about 30 senior leaders and physicians from across every major area of the organization. We sift through those ideas that are currently ranked based on those numerical scores and then we start to challenge assumptions. We ask each other what we think will work with this particular idea and try to whittle that down to the top four or five that we’ll end up choosing from to go into the program.

We do things a little bit differently than some of the other systems I’ve seen. This incubator is just for our employees and our physicians. It is specifically designed to develop Orlando Health’s intellectual property. The person who brought the project forward will drive it. They will be in charge of budget, if it gets to that point, and coordinating with the work group.

But at the end of the day, it is Orlando Health’s intellectual property. We will work with them to license it out or sell it. We will pursue those paths before spinning out something as a separate business. Then if it is profitable in some form or fashion, the person who brought that idea forward gets a significant portion of those those royalties.

A number of our key physicians said over the years, I’m working on stuff, doing research, coming up with these ideas, and I have nowhere to take them. I would love for Orlando Health to be the organization that drives this stuff forward. But until a couple of years ago, we didn’t have anywhere for them to go or any support to offer. Now they are excited that there’s a pathway for this stuff.

What kind of employees or physicians bring in ideas and what stage are those ideas in?

A year and a half ago when we first started this process, announced the concept, and opened up applications, we had no idea what we were going to get. We were pleasantly surprised across all fronts. Last year we had just over 60 applications. I would say probably 10 percent of them had a working prototype or very thoughtful design.

The rest were early-stage, sketch on the back of a napkin sort of concepts. That helped up shift a little bit to accommodate ideas at that stage. They need a lot more due diligence and a lot more planning to get to a place where we can start to build prototypes and things like that.

We’ve gotten ideas from almost every corner of the organization. Physicians have definitely been a lot heavier in the mix than other types of team members, and the physician ideas tend to be more developed. Sometimes they have put their own personal funds into developing it just to see if the concept works.

How do you determine which ideas have commercial market potential beyond solving Orlando Health’s problem?

My selection committee helps assess it. We pick people with different types of experience and backgrounds. We have a handful of people here that have worked in early-stage companies and have some of that insight. That’s where Healthbox as our partner comes in. Behind the scenes, they’re helping us guide the whole process, helping us with our criteria to move ideas forward. They also produce some pretty comprehensive research on each of the idea, such as a market scan and competition analysis, so we know what we’re looking at. Then an assessment of the resources the project might need to get each of those ideas to prototype and minimum viable product.

Do you get involved in whatever happens next in terms of actually creating a company around the idea?

We’ve staged it out appropriately to account for making sure that we’re staying on track, that things aren’t getting ahead of where they should be, and that we’re not setting aside too much in the way of funding. Each year, the four projects that go through the foundry process can come back and do a “Shark Tank”-like pitch to our executive team and other senior leaders and ask for a budget for the next 12 months.

We stage it out in 12-month increments to make sure that it’s manageable because these people still have their full-time jobs. Our funding allows them to set aside a set number of hours every week and those funds reimburse their department or practice so that their department is not losing anything with this person working on the project.

Mostly what we set aside funding for is bringing in external resources, whether it’s a software developer or a biomedical engineer to help us draw something out in CAD. We have checkpoints throughout that process where our team, other internal resources that we’ve lined up for assessment, and then Healthbox are making sure that those projects are on the right track and advancing the way we think they should.

But we’ve also said that overall, going through the foundry and getting to the end of that process does not mean that it is market ready. The foundry itself is one of the steps for validation, making sure we can put the idea through the paces. Will it do what we think it needs to do? Does it end up conflicting with other vendors we have or internal resources or processes that are in place? That process helps us understand how this would end up looking if we were to scale it across one facility or the entire organization.

Then if it continues to check out throughout that process, we start looking at who we would likely license or sell this to. What type of partners would be ideal? We haven’t had any projects get to that point yet, but we have a few that we’re starting to scan the horizon.

What does your team look like?

It’s a very small team right now. I feel like a one-man band most days. The senior executive that started this process is essentially our chief strategy officer. His title is senior vice-president of strategic management. Our broader team is responsible for all of the strategic planning and execution across the entire organization and we are tucked alongside that. It’s myself and an analyst who works for me.

But then we have the committee, and then a number of people throughout the organization have expressed a strong desire to partner with us to help the program continue to grow. We lean on a different person across that network based on what we need. What’s helped us be successful in standing this up so quickly is bringing in what I call adult supervision, a partner who’s experienced in this, like Healthbox.

What did you bring back from HIMSS19 that is most applicable to what you’re doing at Orlando Health?

That was my first year going. It is completely overwhelming. It was really hard to take in everything that was there. I almost wish it wasn’t so big.

But it’s fascinating to walk the vendor floor and see who the big players are. We have someone who helps us on our venture fund side and he said, “Start to look at the smaller companies that are on the periphery that have a really small space. When you come back next year, see who’s moved inward a little bit. See who has a bigger footprint. Pay attention to those types of moves.”

We were also looking at broader themes, trying to get a sense of where some of the technology is going, where some of these segments of the industry are going. It is so encouraging that healthcare in general is rapidly changing and the notion of digital health and that entire segment of companies and products and technology has really started to take off.

I sat through a number of presentations on the expo floor where they were demoing. Seeing the way that AI, chatbots, and virtual assistants are starting to impact the patient experience was cool. That was one of the things I took back to our team and relayed.

Patient experience is one of our top priorities this year, to solidify how we deliver a consistently excellent experience. We don’t always have the right tools. Historically we’ve had some silos, where different forms of technology that we had implemented didn’t necessarily talk to one another.

I’m trying to look at things from a 30,000-foot view and figure out where we can start to weave some of this stuff together, to see what’s available on the market that we could plug in and where there are gaps where  we could create something internally that would help us move quicker.

HIStalk Interviews Nora Lissy, Director of Healthcare, Dimensional Insight

February 7, 2019 Interviews No Comments

Nora Lissy, RN, MBA is director of healthcare for Dimensional Insight of Burlington, MA.

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Tell me about yourself and the company.

I’ve been a registered nurse for over 30 years. I started out as a clinician, with the majority of my time spent in the emergency room. I then got interested in hospital operations and working with the operational folks and leadership. As healthcare evolved, I evolved with it and got into analytics, understanding numbers and outcomes. I used Dimensional Insight’s system in three different organizations in three different roles and found that I loved what I was able to do with it. I came on board with the company in 2013. I help organizations understand their information, their data, and to get the right data to the right people so that they can act upon it.

Do health systems underuse nurses and other clinicians in using data to make decisions?

Yes. Our president likes to talk about the “data gene,” which some people have and some don’t. Every organization definitely has pearls — not only nurses, but lab and rad techs who actually understand the global picture. There’s always one person in every department where everybody knows that if you need an answer, you go to them. Those people are usually data-driven to begin with, just naturally.They do get underutilized, or shall I say mis-utilized. They have their regular job, and then when they have a chance, we’ll  have them do reports and stuff like that for us. But some very strong care providers are also analytical and would be helpful in pushing forward the analytics process.

BI and analytics tools triggered a buying frenzy. What was the result?

Like you said, it was a frenzy. Everyone felt like they had to get it. Many people are influenced by pretty pictures, or they go down a path and they’ve got someone who’s caught their interest.

What I’ve noticed in working with customers and in the literature is that sometimes customers take on too much. BI is a journey. When an organization tries to do 15 projects at the same time, it’s inevitable that none of them will get finished. A project gets started. Then it’s like, OK, this is cool, we can use that same tactic over here. They start big project B before finishing big project A, with the same people working on both. Now you’ve pulled them in two different directions and nothing gets finished.

The successful ones that I’ve seen have stayed within the guidelines of their strategic plan. Some people feel it takes too long to get that done, but you need to have a plan, a path you’re going down. Not just say, “We’ve got BI and we can do everything.” Every tool can, but you have take the steps and do it and close the loop before you go to the next one.

I’ve worked in organizations that had four or five BI tools, so they had four or five reporting teams. They still had the same problem — my BI tool says this, your BI tool says that. They never really got together and said, what do we say as an organization?

Does BI get the credit way down the line when the decisions it influenced finally produces positive, measurable results?

I think so. What I’ve seen is that there’s a big fervor at first. Everybody gets it, they see stuff, and they go wow.  But a BI install suddenly provides access to a lot of information. That’s the other “aha” that gets you. We have all this data and we don’t know what to do with it. We had none, now we have too much. How do we core it down to what’s going to be meaningful to us?

That’s where I think the BI tool can come into play, to help us focus on what we need to focus on because we have so much out there. Healthcare is just loaded with data, and more comes in every day. We want to use these complex business rules and these algorithms, but we could have obtained the same answer if we had just used a quicker approach.

Health systems have all this new data, multiple teams, and a mix of acquired health systems and practices using different systems and different terminologies, plus trying to decide whether to centralize the analytics function. Do these factors make it tougher to do analytics right?

Absolutely. It’s an absolute challenge, everything you just said. You might have a hospital organization that has been using an embedded BI tool for years. Then all of a sudden they acquire, or they’ve been acquired. They decide that they don’t want A, or they really want B. Then you have to go through a conversion of what they’ve done. Aside from just the acquisition process, you have to work on linking and cross-walking different EMRs or even the same EMR implemented with different approaches.

I’ve worked in two organizations that had four or five reporting teams. We were chasing our tails. Who do you believe? Who has the loudest voice this month or with this leadership? The people who really need the BI, the operational and front-line people, throw up their hands and say, “I don’t even know what I’m getting any more, so I don’t even care.” You look at who is using the BI and there’s little utilization. The people we’re trying to help don’t even get all the information they need because there are too many competing answers.

I find that the best success is when you bring in not only stakeholders, which is your leadership, but also the people that you’re expecting this data to help. They need to be a part of the process. You can’t just put this together and say, here you go, you’re on your own, take it and run with it. You have to bring them into the process so that they understand the value they’re getting. It’s one thing bringing a BI tool in, but what’s the value I’m going to get from it? Is it just one more report that I have to go through, or will it give me value and make my day better?

My experience is that the people who use analytics the most are department managers and directors instead of C-level executives who don’t even have computers on their desk. Should the C-suite be involved or pay more attention to what data is available and how it’s being used?

I would say that over the last two or three years, I’m seeing more and more C-suite involvement. I have a couple of customers that if the information isn’t available when the CEO comes to work, he or she is calling and saying, where are my numbers? So I am seeing more senior suite involvement.

There are two types of BI – the “how are we doing” numbers for the C suite and then the operational things, which are near and dear to my heart. The things that I had to do as a clinician or as a manager of clinicians. The things that I needed to arm them with. We can give that to them. Before, we would have to go through 15 reports to try to figure it out. It’s making their life easier.

There are so many rules and regulations coming out in healthcare. I have to remember to dot my I and cross my T. Maybe if I had a queue list to tell me that these are the three things I have to worry about, that would make my life easier.

It’s like anything else you do in life. It’s a daunting task if you have a room full of garbage and you have to decide where to start. You have to pick at it and say, I know I’m going to keep the stuff over there. That’s one fewer thing I have to worry about. From a BI perspective on the operational side, they see their page with their three things and they’re all green and they’re good. If one is red, they have to go focus on that. It’s helping them get through their day-to-day operational side.

We haven’t quite gotten the value from BI because healthcare and the operational side of things are complex. When I say operational, I’m thinking about your clinical folks. Was the assessment done in 24 hours? When was the last time case management saw these patients? There are standing operating procedures that are in place that if something goes wrong, we might stop and take a look at it. But generally speaking, it just goes along day by day until the holes in the Swiss cheese line up and you realize you should have been seeing this. But life’s busy in the hospital. We need to provide actionable information to the day-to-day providers so they can prevent the harm.

What new data elements are available for that alerting and trending analysis and how are they being used to impact individual patient care instead of just giving executives a stoplight report?

It’s more the capacity of how BI itself is evolving and how data is being pulled. The old world of BI was SQL queries. Now you’re getting into columnar databases that allow for a faster retrieval and for more data to be viewed at one time. That technology allows you to cipher through millions of rows of data. 

Think about it from a lab perspective. When I was at a healthcare organization in North Carolina, I worked with a clinical pharmacist to identify the five or six high-risk drugs that they wanted to have insight into. Then we got a tickler every time the lab values changed. We added the information to their hourly census, so that when the lab values came in and the patient was on this particular medication, they would see the trend before it got to a critical point. They would see that it’s been rising for the last two days by 0.2 percent each time, so we had better keep an eye on it.

It becomes more useful with the ability to visualize and manage more data at one time. I have another organization whose pharmacists use it to look at critical medications. They bring in over 40 million rows of data to use their work queues to improve their movement from IV antibiotics to PO antibiotics so they can lower cost, improve patient care, and hopefully get the patients out of the hospital sooner than later.

The BI approach uses technology to highlight exceptions to the defined desired values, while the machine language approach would be to throw a lot of data at the system to identify new problems or opportunities that humans have missed. How do those approaches co-exist?

Machine learning has a way to go, in my opinion. Someone still has to feed that machine some kind of algorithm, and it has to know what it’s looking for. Some are more sophisticated and can do patterning and I think that will become invaluable over time. It’s not mature yet, where physicians believe that it shows them what they expect. But it will be an invaluable asset as it continues to grow and as we continue to understand how all the data fits together.

Why have we stopped hearing the most overused term on the planet, “big data?”

Because everything is big data. It was just a catch phrase. I don’t know where it started, and then all of a sudden, it just went away and no one is even saying it any more. This may sound ignorant, but it’s the same thing when we talk about AI and machine learning. What do we mean by AI and machine learning? What concept do people have of that? What are the developer’s concepts? What do its potential users think? It raises the same kind of question as the term big data.

Do you have any final thoughts?

I really enjoy what I do now because I get to work within my passion in using analytics to help providers — who need it more than anybody else – and to help the operational folks with their daily operational process that is very difficult. There’s a lot of expectation that the people on the front line will get things done, remember all these rules, and do all these things. As we move forward in analytics, we will hopefully be able to make that life easier for them and help them focus on getting back to taking care of the patient.

HIStalk Interviews Terry Edwards, CEO, PerfectServe

February 6, 2019 Interviews No Comments

Terry Edwards is founder, president, and CEO of PerfectServe of Knoxville, TN.

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Tell me about yourself and the company.

I started PerfectServe in the late 1990s after spending a few years in a technology company called Voice-Tel, which was one of the early pioneers in interactive voice messaging. At that company, I saw the need to improve communications in healthcare and later started PerfectServe. The company started in managing communications in the physician’s office, extending later into managing nurse-to-physician communication in the hospital and acute care environment while still doing the physician work. We evolved that over the last several years into one of the most comprehensive communication platforms in the industry.

How will the mid-January acquisition of Telmediq, the top-rated secure communications vendor, change your business?

PerfectServe was acquired by the Los Angeles private equity firm K1 Investment Management in the middle of last year. That was part of the plan to get our early venture investors out. They had been invested in PerfectServe for a long time and stood behind the company. We were able to give them a successful exit.

With that, we were also able to clean up PerfectServe’s balance sheet and to gain the backing we needed to execute on a broader strategy. As you and I have talked about in the past, the industry in which we operate is that outside the realm of the EMR, the technologies are fragmented. We started to see this just in the fragmentation of communications alone. But in addition, other technologies that are adjacent to communications could be part of a more comprehensive platform.

We surveyed the landscape and saw the opportunity to consolidate some of the stronger players within our category. Telmediq was at the top of that list. It had capabilities that we did not have, such as in the contact center and call center space as well as in nursing mobility. We thought those would be valuable to our customers. While there’s overlap in what both companies do, Telmediq was doing some things better than PerfectServe, and PerfectServe was doing some things better than Telmediq. By bringing these two together, we believe we’ve created the leading communications platform in the marketplace.

How important is it for a CEO to work with investors who can help take the company to the next level or help it clarify its acquisition and positioning strategies?

K1 is a growth investor. There are different kinds of private equity firms and different business models. Some will find slower growth opportunities with companies that might be growing five or 10 percent a year, then put two of them together and then take out costs and try to drive synergy.

K1 is a growth company where they are looking to invest. They are about building leaders in the category. As they evaluated PerfectServe, one of the opportunities was that PerfectServe could be the cornerstone of a much larger and broader care team collaboration product offering strategy. That led to the opportunity to acquire Telmediq.

We just announced two other acquisitions. Lightning Bolt Solutions, which is in the physician scheduling space, and CareWire in the patient communications space. Our broader strategy is to build the care team collaboration platform of the future. We will do this through both acquisition — and integration of the acquisitions — as well as organic development. That takes capital to do well, which is why we have K1 at the table with us.

Was the death of pagers greatly exaggerated?

[laughs] They are dying a slow death, but there’s a long tail.

Consumers seem to be using phones more often for texting more than for making phone calls or sending email, and now they are using speech recognition to drive that messaging. How is that  impacting healthcare communication?

I’ve been amazed to watch the adoption of texting as a mode of communication. When we started PerfectServe, everything was voice driven. In fact, the first version of the PerfectServe platform was purely an interactive voice response platform. All the communications were voice driven and interacting with the keypad.

We first entered the acute space in 2005. Due to the nature of the platform, 100 percent of the communications we were processing were over the phone, either as a live call or sending a page or text message. The text messages could be as an alphanumeric page or SMS and they were all system generated.

We later introduced our web interface and then our mobile interface. With mobile came texting. We started to see texting rise.

About 18 months ago, we introduced a new user object so that nurses could authenticate in the same way as our physicians. With that, we were able to facilitate bidirectional communication. A nurse can send a text to a doctor via the secure platform, then the doctor can reply. In our newest hospital environments, 90-plus percent of all the communication that’s running through the platform is text, and it is secure text, which has been fascinating to see. It’s convenient and that’s the benefit.

What is being done to make communications part of the overall workflow?

Gartner has classified us in the category of clinical communication and collaboration, or CC&C. They gave it that name to help communicate to hospital buyers that communication is more than just secure texting. Secure texting is a component of a broader communication strategy.

But as we’re looking at this — and I think it’s consistent with how Gartner is looking at this – the clinical communication platform is a core component or pillar of a broader care team collaboration platform. It needs to encompass the communication modalities of secure texting, paging, SMS messaging, email notifications, and voice calling, whether it’s a cellular, voice over IP, or landline. You have to have this omni-channel communications component.

The key to PerfectServe since Day One has been our workflow capabilities. We are automating a communication workflow to make sure that we can connect the initiator – a nurse or a doctor or some other caregiver — to the person they need to reach, who can then take action at that moment in time. Workflow is a component of this.

As you think about workflow, there’s not only the algorithms around routing, but also call schedules. PerfectServe as well as Telmediq built call schedules into our platforms, but they were limited to the schedules specific to a communication workflow. Medical groups, for example, have scheduling needs that are broader than that, that go across the whole workforce. That is where Lightning Bolt comes into play.

These adjacent technologies move beyond communications to staff scheduling, referral management, rounding, and integration into other technologies like alarms, alert systems, nurse call, and interactive patient care. Our vision is to build the most comprehensive care team collaboration platform, either by building or acquiring technologies that make sense to be a part of it, and then integrating with those that are adjacent but outside the domain, such as nurse call.

How have the communications needs of health systems changed as they acquire hospitals and practices?

I don’t think they are changing, but the expansion is enabling them to put in stronger governance structures to drive higher levels of standardization. One of our clients, Advocate Health Care in Chicago, has been a model in terms of saying, these are the parameters upon which we’re going to communicate with you. We’re going to have these minimum standards around fail-safe notification processes and escalation and things like that. This starts to move the organization away from letting doctors do it however they want, which might be might be efficient for them but not for nurses or colleagues who need to reach them.

What do you as a CEO do during the HIMSS conference?

[laughs] It’s usually a pretty packed schedule. I will spend a little bit of time in our booth, and that’s unstructured. But for the most part, I’ve got meetings scheduled, a mix of customer meetings, new prospect meetings, analyst meetings, and sometimes meetings with folks in the financial community. It’s usually a pretty intense time, one of those events that I look forward to, but that I also hope to never attend again.

Do you have any final thoughts?

I’m excited about where PerfectServe is. Not just for me personally or our company, but for our customers. I’ve been in this space for a long time and I’ve seen a lot of things. There’s this bigger vision that I started to see about three or four years ago and it is here now. PerfectServe and our customers have the opportunity to deliver even greater value than I envisioned. I’m excited about that and excited about the future.

HIStalk Interviews Jason Krantz, CEO, Definitive Healthcare

January 28, 2019 Interviews No Comments

Jason Krantz, MBA is founder and CEO of Definitive Healthcare of  Framingham, MA.

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Tell me about yourself and the company.

Definitive Healthcare was started in 2011. Our goal is to be the premier provider and the single source of truth for all data on healthcare providers. In the last seven or eight years, we’ve grown significantly. We have about 320 employees today. We offer detailed information and analytics on every single provider in the US and Canada.

Why did HIMSS sell its HIMSS Analytics business and how did Definitive Healthcare end up acquiring it?

HIMSS Analytics has tremendous data assets around technology, infrastructure, and contracts. The match with Definitive is about being a good shepherd of that data. By combining that information with all of the proprietary data that we have around affiliation, quality of care, and now our commercial claims database, we’re able to provide a complete picture for our clients that will give them a competitive edge.

Those clients include companies that are marketing into the healthcare provider market as well as providers themselves that are looking to expand their networks and understand where they can continue to grow their business through physician referral, analytics, and new affiliations. We offer a powerful solution to help advance the industry forward.

HIMSS is keeping the Adoption Model business and the consulting around that, right?

That’s correct. They’re going to continue to provide the EMRAM and the consulting around it. We will focus on the data business and the detailed provider information for both the vendor community and the provider community.

How have mergers, affiliations, and network agreements changed the demand for information as the market gets more complicated than just single hospitals and health systems?

“Complicated” is the operative word. As this industry continues to evolve and health systems become these extraordinarily complicated organizations that are big businesses in their own right, all the participants in this industry need to have access to data that can help them decipher what’s happening. Where are patients going for care? How do all these facilities interact with each other?

More and more, we’re helping our clients understand where there is patient overlap or leakage from one hospital to the next. Our clients are trying to solve that for providers, while the providers are trying to figure on their own how they can continue to protect their business and deal with new payment models. The complexity helps our business over time.

Will these larger corporate entities impose a corporate standard for systems such as EHRs and revenue cycle?

The speed at which mergers are taking place certainly makes that difficult from a technology standpoint. Health systems by and large have the strategy of moving to a corporate standard, but it takes time. Technologies that help these systems talk to each other become increasingly important.

The other important corporate standard is around decision-making for medical devices and pharmaceuticals. Health systems are trying to create standards across their entire organization. That’s good for healthcare. Standard therapies help patients overall and help understand new therapies that come to market. The move to control everything within their network continues, even though it is complex with the technology infrastructure.

Where will the three main inpatient EHR vendors look for opportunities now that the market is saturated?

They are doing some pretty interesting stuff, such as starting to work with insurance companies and different types of facilities such as treatment facilities. Epic is the largest EHR that works within the clinical trial space, which is an interesting way of growing for them. You’ve got all this rich patient data that needs to be collected in one fashion and Epic does well in that market. We’re rolling out a clinical trial product to address the needs of the pharmaceutical companies and medical device companies that we serve, but also the technology companies that want to get a piece of this robust market.

Even though they’re relatively saturated within the hospital and the health system market, these tangential areas are exciting growth areas for them. They open up a new opportunities in life sciences, insurance, and other areas.

Are drug and device manufacturers more interested in using the information that a typical hospital or practice would collect?

Absolutely. Data from EHRs has grown so much and become more standard over time. It’s a tremendous opportunity for improving the quality of care by analyzing that data, getting newly available information and at a larger scale across larger patient populations. There’s a massive interest in getting access to that data from the pharmaceutical side.

What kind of information could a mid-tier hospital software vendor get from you that would help them understand their potential market?

We have data on every single provider in the US — clinics, physician offices, imaging centers, hospitals, and IDNs — and the affiliation of all these facilities. It’s important to know whether they are owned by a health system or are standalone. We have the technology infrastructure data that allows understanding what each of those facilities are using. That data has become stronger through our acquisition of the HIMSS Analytics business. We also have information around the quality of care provided and the Medicare penalties or incentives that each of these facilities is achieving.

All of that is important for these organizations that want to elevate the conversation with their prospective clients. Rather than going in to talk about their product, they can go in and talk about what’s happening at the facility or the health system — the problems they’re seeing in their market and how that compares to other facilities they have. They can use that data to bring their product to life and show those prospective clients why their product can help meet the needs of that organization right now. Making your team smart and targeted to understand the business problems of the hospitals and facilities is an important value-add that we bring to our clients.

How do you see the company changing as it grows?

Our goal is to continue our product innovation. We have grown, mostly organically, over the last seven years at a rate of something like 175 to 200 percent per year. We continue to grow by selling more of what we have. We have a very good product of extremely high quality that covers the market really well.

We are also innovative in what we roll out to clients. In the last year, we’ve been more innovative than in the first six or seven years of our existence. We rolled out a commercial claims database that gives our clients access to data on about 210 million patient lives. We have over two billion claims. This allows our clients to understand diagnoses and procedure utilization rates by facility, provider, or physician. We’re rolling out a clinical trials database, and later this year, we’ll also be rolling out a database with specialty pharma data.

Our goal is to continue to stay on the forefront of new trends that are happening within the marketplace. Each time we do this, we open up a brand new market that we haven’t sold to before. Clinical trials opens up a multi-billion dollar industry for us. Commercial claims gives us access to all of these new markets we haven’t sold to before that need to understand what’s happening in the commercial market. All of this innovation helps us continue to grow.

Over time, we’ll continue to pull in more information, maybe from EHR systems as you mentioned, to help clients analyze that data. That’s potentially something down the road. We’ll start to get into more of health economics and outcomes research. That’s a great market for us. We see the runway as being extraordinarily long. We’re going to continue to grow at the pace that we’ve been used to over the last five to seven years.

Who are the prospects for the all-claims database and how can you correlate that information with your other databases to provide new insights?

Most of our client base is interested in the commercial claims data. Certainly some core markets are life sciences, providers, and tech firms. We take this data, where you can see this utilization by facility and physician, and make it extremely powerful by combining it with all of our proprietary data. Now you can start to do things like roll that data up at the IDN level. What does an IDN look like for knee replacements or other procedures or diagnoses? You can also combine it with things around the quality of care analytics that we provide.

Our clients take this claims data that’s valuable on its own, but we bring it to life and make it an actionable piece of information that they can use to define a new drug launch or develop their markets and create a go-to market strategy for whatever product they might have.

Do health systems use your information for competitive purposes?

We have lots of health systems as clients. They’re using our data to develop their networks, which of course is competitive to some extent. They are looking to develop new physician relationships based on referral patterns. They’re using our data to find merger and acquisition opportunities. We help analyze leakage outside of the system, Our clients are interested in understanding that. They can start to fill those gaps, because any time care is delivered outside of their system, it’s harder to provide the quality of care at the cost that they want to provide it.

How do you see the company’s future over the next five or 10 years?

It’s about continuing to expand our product offering. We have a big team of people that are being highly innovative in thinking through what the trends are within the industry. We can help our clients meet those trends head-on and stay in front of them. Access to our data and our analytics gives our clients a competitive edge. This market is moving fast. To be competitive, our clients need to stay ahead of the trends and we need to help them do that.

Over the next five to 10 years, we’re going to continue to evolve, add new product offerings, and potentially do more acquisitions as the market continues to expand so that we can provide the best data to our clients to meet their needs.

Do you have any final thoughts?

We’re a fast-growing company and there’s a lot of responsibility that goes along with that. We invest a tremendous amount from our company in terms of helping our employees grow as individuals and also to give back. We launched the Definitive Cares program about two years ago, where we have 100 percent of our employees doing a community service project throughout the year. They earn days off by being part of this program.

It’s an important part of our culture because healthcare is about helping people and servicing people. We want to bring that into the fabric of our culture. We help over 30 charities every year. We have a 100 percent volunteer rate within it. As a company, we gave over 3,000 individual service hours during the working day. All of that is important. My final thought is that continuing to give back is important to all corporations. We try to live that on our own.

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