HIStalk Interviews Reed Liggin, CEO, SlicedHealth

Reed Liggin, RPh, MBA is co-founder and CEO of SlicedHealth.

Tell me about yourself and the company.

I went to University of Georgia College of Pharmacy and got into healthcare as a hospital pharmacist. I got  an opportunity to get into health tech in the e-prescribing field in the late 1990s. I worked for a California company that flamed out in the dot-com bust of 1999. I worked briefly for Allscripts as it was becoming an EHR company, and from there I went to McKesson and started selling the number one hospital pharmacy system in the market that they had acquired. I built my career at McKesson, which is where I really learned the business.

I started my own company, RazorInsights, in 2009 with a couple of friends from McKesson. I worked there for almost three years and we had an exit in 2015 to Athenahealth. I was then hired as CEO of EazyScripts in Chicago. We were doing e-prescribing for telemedicine. We successfully sold that company in the spring of 2019. From there, I got together with one of my co-founders from the Razor days, Mike McKenzie, and three other seasoned health tech guys who had worked for us at Razor and Athena to start SlicedHealth.

Our goal was to solve the payer contract intelligence problem for community hospitals, which largely lacked solutions. Going back to the Razor days, we got asked about contract management and payer contract intelligence a lot. As the problems of denied claims and underpaid claims exacerbated over the last few years, we saw a great opportunity to serve that part of the market. 

Today we serve 140 clients in community hospitals under 400 beds across the country, and many of those are under 100 beds. We also have some larger health systems, and we also serve specialty practices like orthopedics, pain management, and women’s health. We offer payer contract intelligence, hospital price transparency, claim estimation for the No Surprise Act, and business intelligence. We recently introduced embedded artificial intelligence, which is called SlicedIQ. Clients can pick any module or combination of modules that suit their needs. We launched in January 2020, just in time for the pandemic, and have been doing this for just over six years

What creates the situation that you call hidden underpayments and what is the financial impact of fixing it?

I don’t want to totally point the finger at payers, but I will point the finger at the payers to a degree. They use sophisticated technology, including AI, to deny claims for various reasons. They are often good reasons, such as where the provider hasn’t put the right information into the claim or has made mistakes on their side, and they are sending it to the payer incorrectly. But often we see systematic denials of claims for a variety of reasons, and we often see claims that are underpaid where something in the contract is not adhered to. It is inefficiency in a highly complex system.

It’s interesting that the customer has to buy the technology to catch their vendor trying to cheat them. Would a payer that doesn’t follow the contract ever be assessed financial or legal penalties?

I’m not aware of any. Providers that are large enough could probably take those things to court and get some restitution. But smaller providers, such as independent community hospitals and practices, have a lot less leverage to fight those sorts of things.

Many people don’t know how bad the problem is. Or they know, but it’s a lot worse than they think. There has been a lack of awareness over the last few years. We saw a big technology gap in certain parts of the market, independent specialty practices and smaller community hospitals. Their core vendor might have a contract management module or some old technology that didn’t do the best job in the world and relied on the client to do the install and maintenance work. It was a big burden for organizations that are already resource constrained. That was the problem we set out to solve.

Does provider adoption of technology level the playing field, or does it just force both sides to one-up each other as in AI wars?

It absolutely levels the playing field and makes the system more efficient. We take in claims data every night through a file drop in the cloud from the claims clearinghouse that the organization uses. As claims are processed nightly, users can review the next morning what hasn’t been paid correctly. You can get on top of these problems quicker and with a high degree of accuracy.

How do large health systems address the issue differently?

Epic and Oracle offer strong native technology in their platforms. As you get above 400 beds, there’s a lot of penetration and use of this technology that we found was not being used in those community hospitals. We had discovered, through our time at Athena and afterward, that a lot of specialty practices were not using that technology as well.

Is it inevitable that revenue cycle is complex when companies are making money from that complexity?

Absolutely. Healthcare is inherently complex and participants can benefit from leveraging that with technology, such as gaming the system by holding on to money longer.

Everybody expected the heaviest use of AI to be in imaging and clinical work, but the big expectations and the gold rush often involve revenue cycle management. How do you run a business around that when AI changes literally every day?

You just described a day in my life right now. As a management team, we are huddling almost daily on how fast things are changing because of artificial intelligence.

I’ll give you a good example. We released our SliceIQ platform, which embeds AI in the payer contract intelligence platform. You had the ability to get step-by-step instructions on how to resolve a claim that had been denied or underpaid, generate an appeal letter, that sort of thing.

We came out with that last November. By January, a half dozen companies were doing the same thing. They tended to be niche companies, startups around AI technology to specifically address mainly pre-adjudication claims issues to prevent them from happening in the first place, but resolving them post-adjudication as well. They were companies that I had never heard of, so we will see if what they are doing is real. We are starting to see some bigger players in the clearinghouse space and the EHR side that are starting to come out with that same sort of technology.

For us as a small company, we have a nice customer base. We were trying to figure out how to solve unique problems in the midst of all this. We are focused on payer contract intelligence, because only a few companies do it and even fewer of them do it well. We are making sure that we carve out what I call our little blue ocean of unique problem solving, while a vast red ocean of people are trying to use AI to automate everything in the revenue cycle.

A payer recently announced that their analysis showed that providers are upcoding, as evidenced by lack of diagnosis or treatment for what they billed. Will it become a trust but verify situation, where providers will need to submit more data or payers will take on the role of clinical auditor?

Absolutely. As the technology enables it, the bar will be raised. You have value-based care as well. We’ve held off moving into that and the jury is out on where it will go, but it seems to be starting to grow. That’s an area that we will help our clients solve.

As a pharmacist, what do you think about how pharmacy has changed? Are you happy with the contributions that technology has made?

It has been overcomplicated by being part of Meaningful Use. Interoperability should have been job one, but it got pushed to the back burner. It doesn’t feel like we are as far along as we should be in some ways.

In other ways, pharmacists in particular are using technology in a very good ways. Nobody has to read physicians’ handwriting any more. We eliminated a lot of safety issues around illegible handwriting and drug interactions that weren’t being caught. From a safety standpoint, we’ve come a long way across all clinical systems.

But it’s still an issue that when you go to a couple of different doctors, if they aren’t using the same system, good luck in being able to share information. We’re still a long way from where we need to be. That’s been frustrating for me as a clinician, where I go to one specialist and then another specialist, they are on completely different systems, and I have to educate them on what’s going on with my whole record and hope they get it right.

The terms CPOE and e-prescribing aren’t used much these days since those are now standard. Will we see other areas where technology will become an expected piece of plumbing that replaced processes that we barely remember?

As someone who is sitting in the claims and revenue cycle space, I don’t think it will get any simpler anytime soon, especially as you introduce VBC contracting and all the data that it will require. The bar will continue to go up as far as what providers need to provide to make sure that their claims are paid properly. Trust but verify systems will ensure that they are getting paid exactly what they are supposed to be.

On the clinical side, I haven’t thought through what will become automated. I assume that prior authorization will get there, but that will still require payers to get some uniformity to make it possible. I tell my team that if you’ve done one claims appeal, you’ve done one claims appeal, because they are like snowflakes. Prior authorization is not much different.

How much of the eventual success of an early-stage company is the result of planning versus just reacting to events as they happen?

I think it’s reacting. We started this business with payer contract intelligence, or payer contract management if you want to call it that, as a goal. But we really started it around business intelligence. Then a pandemic happened, the price transparency law came along, and the No Surprises billing act came along. We just continued to react to those things. They led us down a path to what has become our flagship product, which is payer contract intelligence. But if you had asked me on day one if that was the path that we would take, I don’t know that I would have said that.

Particularly with AI and how fast things are happening, you have to react well to change. You set a plan, but you will have to adjust that plan. We like to stay focused. We have had a lot of opportunities to build other things in the revenue cycle besides payer contracting and price transparency, which uses essentially the same data. We have resisted that, because we want to stay focused. Having built a whole EHR system, with clinicals and financials [laughs], I’ve learned that’s certainly a better way to run a business.

Do you see a day where AI allows tiny companies that have few employees to be major players in health tech or healthcare in general?

I do. We have a project going on where we have been able to do some amazing stuff with AI, and we will be pushing out a couple of new products in the next couple of months. Really it was one person who was behind all of that. AI is going to create opportunities for people to create things and fill in gaps. What I’ve always done in healthcare is to look for gaps where certain providers were underserved or missing capabilities or services that they needed. AI will give people the ability to get there faster with a lot less capital.

What is the company’s strategy over the next few years? 

We want to continue to be known as the best, fastest payer contract intelligence company in the market. We will continue to push up-market. We focus on three key things for our clients. Taking the work off their plate of the build and maintenance of the system and getting them live faster than traditional companies have, and using AI to lean into that those two things to service our customers better. The third thing is making our pricing as low as possible. Obviously as a for-profit company you want to keep decent margins, but as we drive our costs down, we will share that with our customers. That will make it a no-brainer for them to want to do business with us.

We see ourselves as a disruptive force because of the way that we build a model contracts faster using technology, and then take the work off our clients’ plates. We will continue to lean into that. Then we will look for ways to expand our value in that payer contract space. We have AI that will give clients advice on how to negotiate a new contract with the payer, what point they should try to negotiate to improve their deal. We are looking at other ways to expand the knowledge that clients will have around payer contracts.

HIStalk Interviews Brent Benner, President, Canopii Collaborative

Brent Benner is founder and president of Canopii Collaborative.

Tell me about yourself and the company.

I was born and raised in Texas up until about high school, then spent several years in the Midwest and Texas. I spent two years as a Peace Corps volunteer in Peru. I got back the day before Thanksgiving in 2008, when the stock market dropped like 500 points and launched the financial crisis. I had studied finance and entrepreneurship in school, but finance was definitely not going to be a good path at that moment. I worked at Microsoft for a while, but I was looking for something more purpose-driven like I had done in Peace Corps.

I was seeking jobs only in Austin and Chicago when Epic called me. I figured that a practice interview would be good, and I had heard good things about Madison. Epic just blew me away, so I took that job and ended up staying there for eight years. I started on the implementation team for Tapestry, which is part of the payer suite. I pretty quickly moved into director of product management for the payer suite and acted as the primary liaison between our clients and the software engineering team to help formulate the roadmap.

Ultimately, I couldn’t deal with those cold winters of Wisconsin anymore, so I returned to Texas and launched Canopii in 2021. While I was at Epic, it was pretty clear to me that a lot of firms provided Epic consulting services, but no one was hyper-focused on the payers. We launched Canopii to do just that, to provide purpose-built consulting for health plans and managed care organizations.

That intentional focus has led to a lot of growth. We started with four consultants in 2021, and now we have about 70, of whom 60 focus specifically on the Epic payer suite.

Epic’s payer suite is made up of a couple of products, with Tapestry and Payer Platform being the flagships. Those are used by health plans, essentially the insurance companies or the payer side of the business, rather than the provider side, although we work with a lot of provider-sponsored health plans that work in an integrated environment between the health system and the health plan.

What problems do you solve?

We primarily help our clients take advantage of the software that Epic has built. We’re not necessarily in the game of developing software ourselves. We work with our clients to implement and optimize the software so that they can get the most out of the Epic system.

We add the most value by bringing a product management mindset and being data-driven. We help our customers understand their operational metrics and turn the Epic complexity into operational clarity. We help them achieve the most with the software to improve those metrics and serve the members and providers that they work with.

How does your client measure the ROI of your services?

A lot of times, it depends on how we’re specifically working with them. We do a lot of implementation, so we’re the firm that customers turn to when they are going to implement the Epic payer suite. The return on investment there is focused on being on time, being on budget, and meeting the operational metrics that they have set as goals. Moving to the Epic system overall generates quite a bit of ROI, but you need to get the most out of it to realize that ROI.

We work with clients in other service lines, such as optimization or our application managed services division. AMS is focused on how we can generate cost savings by providing a managed services model in a more cost-effective manner while still delivering better quality. Then, what results can we deliver to your operational metrics?

For instance, a client that we are working with for AMS has decreased the interest and penalties they are paying by $10,000 a month. They have increased their auto adjudication rate, which is one of the most important metrics for payers and ultimately leads to significant labor cost savings.

How many of Epic’s customers use Epic’s Tapestry and Payer Platform?

About 50 organizations use Tapestry. It acts as a core administrative system for processing claims, enrollment eligibility, and medical management, such as utilization management, case management, and population health. A lot of those 50 organizations are provider-sponsored health plans.

Payer Platform focuses on interoperability between payers and health systems. That has been growing like wildfire. All of the largest commercial standalone health plans are now using Payer Platform.

Like with just about every other Epic product, Epic ultimately wins. We are seeing the large standalone health plans start to implement other components within the Epic payer suite, such as Blue Cross and Blue Shield Louisiana, as well as Humana implementing the medical management suite. Over the next couple of years, we’ll see some of these organizations take a look specifically at Tapestry and the claims processing applications too.

When you worked at Epic, how challenging was it to start working with organizations that aren’t health systems?

Most people who work in this ecosystem would have no idea that Tapestry was one of the first applications that Epic launched. They were working with a lot of staff model HMOs and provider-sponsored health plans, but obviously the core focus was on inpatient ambulatory and revenue cycle. Epic clearly established itself as the number one player in those particular markets.

It made sense for Epic to redirect their investment into other areas outside of the traditional four walls of healthcare. That is why you’ve seen growth in areas such as life sciences, but also within the payer suite. It was exciting as the director of product management to see those dollars start being redirected to invest in the payer suite. The payer suite has essentially been number two in investment since around like 2019.

How were you were involved with Epic’s significant investment in money and headcount to implement Kaiser?

Payer suite was  put on the map when we sold Tapestry to Kaiser, which had 11 million members. This was a $1 billion project overall, a little less than the $4 billion that was quoted for the health system, but parallel paths. They followed the same parallel path when the Northwest region and Oregon pushed Epic in the early days for the health system, but it was Georgia that implemented Tapestry and had real success there. That ultimately pushed the rest of the Kaiser organization to adopt it as well.

Our team had been 20 people on implementation and maybe 20 to 30 on R&D. All of a sudden, implementation was essentially 60 people and R&D grew to over 60, which could have even gone significantly higher than that just for Tapestry alone. The payer suite division grew to a couple of hundred people.

What did you learn in being an early-career employee who was put in charge of this massive project that was unlike Epic’s previous work?

An opportunity to have a career at Epic is incredible, because they take a bit of a sink-or-swim mentality. If you can survive and swim, there’s nothing like the opportunity to grow and be challenged. It’s an opportunity to rise, but it is stressful at times. We had some long weeks when we were doing the Kaiser implementation. But that completely exposed me to the industry and the ability to make an impact for Kaiser’s 11 million members. It was a phenomenal experience for sure.

What is the status of payer-provider collaboration and who benefits most from it?

I would hope that our patients, our members, and we as a society stand to benefit the most. We have over $500 billion in wasted administrative spend in healthcare year over year. We are called Canopii Collaborative because we truly believe that the only way that we can reduce that wasted administrative spend is by focusing on helping payers and providers collaborate to seek opportunities where we can do better data exchange, reduce unnecessary exams and tests, and change the model by how we pay and finance healthcare in moving from fee-for-service to value-based care to ultimately reduce that administrative spend.

We at Canopii established ourselves as the primary firm that you should turn to for the Epic payer suite. To start to bridge that payer and provider collaboration, we acquired Anchor Healthcare Consultants, which focused on revenue cycle. We are continuing to focus on that area.

Between CMS-0057-F and other regulation around interoperability and payer-provider collaboration, I have a lot of hope. I also have a lot of hope that AI will help accelerate this initiative and get us there faster. It is fundamental to reducing the total cost of care in this nation, which is frankly unsustainable.

How did your background prepare you to run companies?

I’ve been an entrepreneur ever since I was a kid. This is probably like my seventh company, but the first one that is truly successful.

My experience at Epic prepared me for leading a company like this. Epic still operates as fairly entrepreneurial. It’s very flat, and they place a lot of trust in those individuals who are essentially leading divisions like I did for the Tapestry team. That definitely prepared me, but it’s very different when you also have to handle all the backend function functions like finance, HR, and operations without the support of those great teams like they have at Epic.

It has been a fun ride, for sure. We were excited to be named the 67th fastest growing company on the Inc. 5000 last year. I’ve read that magazine since I was in middle school and an aspiring entrepreneur, so that was a pretty big milestone for us. We are excited about the growth to come.

How did you meet the challenge that faces most companies, but especially consulting firms, to create and maintain a culture?

It is cool to see team members who come over to Canopii who have typically worked at other consulting firms. The comments that they share with us are exciting. What makes the biggest difference is that we treat them as people and not just another number. Perhaps most importantly, they enjoy that we actually understand what they are doing day-in and day-out.

I previously worked at Epic. Our other co-founder was at Epic as well, and then worked as a consultant for a few years. We have maintained a culture where we understand what it is that you do day-in and day-out. We are here to support you. People have gotten into the mission and then the ecosystem that we have created. If you are struggling with an issue, you aren’t sitting on a deserted island. You can come and work with all of the other 60-plus experts that we have in the Epic payer suite to identify someone who has had a similar issue, then work together to bring that back to your client and add value.

What is the company’s strategy over the next few years?

A big focus for us will be expanding our application managed services team. We’ve seen a trend towards managed services over the last couple of years, I fundamentally believe that AI will accelerate that trend. We are focused on working with our clients there, because when we have the opportunity to support them end to end, we can make a significant difference. We are seeing the turnaround on some of not only the IT metrics, but more importantly, the operational metrics that we’ve been working on with our first AMS client. That will be a real focus for us over the next couple of years.

Healthcare in this country is, unfortunately, systemically and fundamentally broken. No single individual or single branch of government can turn that around. It can be overwhelming, particularly at the macro level.

I encourage our customers, other vendors, and our team to adopt the Boy Scout model and leave it better than you found it. Identify the particular area where you can make an impact. Even if you are just one analyst at one client, you can make an impact. Or you may be the CEO of a vendor that is seeking to make a difference between payer and provider collaboration.

Everyone can ultimately contribute to making those small impacts. Then, in aggregate, hopefully we can start to move healthcare towards a model that’s more sustainable for us as a country.

HIStalk Interviews Walter Stewart, CEO, Medcurio

Walter “Buzz” Stewart, PhD, MPH is co-founder and CEO of Medcurio.

Tell me about yourself and the company.

I have focused my career on working with data, from epidemiology training to leading research centers and startups.It defined my path, both in education, where I earned a PhD in epidemiology and was a professor at Hopkins for a while, and with my first startup, which was data-based.

I had a 16-year journey through two health systems, where I founded and ran research centers. I realized from the problems that I was experiencing that it was going to be difficult for AI and automation to work at scale.

I ended up where I never would have predicted, which is in the EHR integration space. I launched Medcurio as a step toward fundamentally solving the EHR integration problems that we face in healthcare. Namely, that it’s difficult to get access to all the real-time data that you need to drive predictive models or other kinds of processes.

How does your product make it easier to get access to real-time EHR data compared to tools that the vendor themselves might offer?

We have used all of those tools. I used them for the better part of 10 to 12 years trying to develop real-time predictive models, first at Geisinger and then at Sutter. Getting real-time applications into production took months, and even small changes took weeks.

It took weeks to more than a month to make changes based on user feedback. It was difficult to maintain user interest with that kind of turnaround time. The application broke from schema changes, which was disruptive and unpredictable. Other downstream functions made it impossible to do things in real time, and we didn’t see that bottleneck going away.

We made up a starter list of the problems we wanted to solve. We built a no-code API platform that installs in less than a day in a health system’s on-prem environment. It erases those problems.

An analyst can log in and build APIs to access any data that they want without writing a line of code. They can make changes to those APIs in minutes to hours. Other features give health systems the kind of control that I wished that I’d had, and that I’m sure that my colleagues wish they’d had, when I was journeying through Sutter and Geisinger.

What competitive or clinical advantages can health systems gain from using real-time data?

This is an important point. It took us a while to recognize that we had been working on real-time use of data for 10 years, so we just assumed that the rest of the market had the same passion. When we launched Medcurio and built our foundation product in mid-2020, we found that we were talking about things in a way that only the top five or 10% of health systems were thinking about.

When I think about using data in real time, I go to a couple of areas that are becoming prominent in the era of AI. One is predicting events, which can be useful in many ways. We often think of it for predicting risky events, such as getting to a heart failure patient before they end up in the hospital. Predictive models can be valuable for that, for inpatient infections, or for a host of other things. It’s a powerful area where AI could have profound influence.

But I think probably the more important areas are in workflow automation, whether that’s back-office workflow automation, or automating a whole process. If you take something like prior authorization, you have snippets of automation, with manual work in between those snippets. The power of being able to move any electronic health record data in real time is that you can put the whole thing together with a set of APIs that power each step in a process and hand off from one step to the next.

How do data latency and completeness problems potentially limit the innovation or implementation of AI solutions, especially agent-driven technologies?

I would list three things. Access to real-time EHR data is limited, latency reduces ROI, and slow iteration impedes improvement.

A unique quality of AI is that, compared to the era before, it will continue to drive unending demand for data volume and data diversity. That will always expand, and if you can’t meet that need in real time, you will have to pull back what you’re trying to do with AI based on the data that you can get.

Second is that maybe you can get only 24-hour-old data by end-of-day downloads. For some workflows, that might work. But for workflows where there’s a lot of ROI opportunity at stake, most of that has to be driven by being able to access all the data that you need in real time without constraints.

I don’t care what automated solution you create, you are always going to have iterations to making it better, and identifying ways that it’s getting hung up. You can’t evolve an automated workflow where after you identify the data you need, it takes months to get it because of infrastructure challenges.

How does your relationship with EHR vendors work when you become a layer between them and their customers, or making sure that vendor changes don’t break something?

We were very aware of those challenges. We developed a technology that is not specific to healthcare. We adapted to a data model. Our technology can talk to any InterSystems Iris database.

We install with the folks on the health system side. They mostly manage the install process, which takes two to four hours. They log into a GUI and can point-and-click to build, test, and then deploy APIs. That process takes anywhere from two to five days.

Our vision was that if I was in a health system, I wouldn’t have to wait in line forever to get something done to meet my demands or needs. This technology is designed for health systems to have control of their data.

What does the health system need to do to use your system in a no-code environment to create APIs that access EHR data?

In an Epic environment, we’ve had Epic analysts in their first year of training logging in and building APIs in an hour. It’s pretty seamless, because when you log in, you’re looking at things in a way that is just logically coherent.

Building an API involves two parts. Who do you want data on, and what data do you want on them? All of that can be done by a point-and-click process.

If you are building APIs for an application, let’s say a prior auth application that might involve a third-party vendor, that vendor just needs to know the API ID. A single endpoint is called for all APIs. That process is quite straightforward.

How are clients typically using the data?

We have seen three categories. One is strategic management of real-time data access. We have a system that uses it at scale in that way. They have rules of the game for how they access data based on priorities, such as using the EHR vendor APIs, FHIR, or some other method. If using these methods will take more than four hours, they use our VennU data access platform instead because it is so straightforward and easy to manage.

Our platform allows assigning multiple role-based users to one API. That gives them quite a bit of flexibility around how one API can be used by different groups. For example, some might have access to personal identifiers and some might not, depending on their role.

We have seen homegrown uses, most commonly real-time display vehicles, whether for inpatient or ambulatory settings.

Some are using third-party solutions. Salesforce is a good example. One system had struggled for six months with data they couldn’t get, and they solved it with our technology in a couple of hours. They went from 10,000 to 1.5 million API calls per day in 18 months after solving that single data access problem.

I think it varies depending upon where a system is on the spectrum of trying to automate or just observe their core intellectual assets.

How is the customer charged?

It’s an annual license based on health system revenue, with support fees. It is designed to motivate health systems to use it to the max.

How does the federal government’s emphasis on FHIR and APIs as an interoperability solution affect your business?

FHIR certainly is one path to accessing data, today and for the future. There will still be real constraints on the narrow sliver of data that you can access via FHIR, because there’s a lot of fields that you can’t access.

Our roadmap calls for developing what we call a FHIR facade for our platform. Because we have flexibility on how we output the data that’s being requested via an API, we can output it in different formats. A FHIR facade feature will allow users to get data in a somewhat FHIR format that could be interchangeable. That would provide greater scale, both within and across systems.

Do EHR vendor decisions or government mandates about data access have any impact on your business?

We don’t touch the data. Our security review is really simple. We install our technology. We coach on how to use our technology. The health system controls it. Our technology gives them access to 100% of their electronic health record data.

Our product talks directly to the InterSystems Iris database. A user who is building an API can visualize things in a way that allows them to easily build the requirements for who they want data on and what data fields they want to access. Once the API is in production, it can be called by any group or application that the security officer designates as allowed.

The power of our platform is that it solves what I would consider to be my greatest challenge when I was a leader of these research centers, which was that I just couldn’t get access to data that I wanted. That was the first problem we wanted to solve, and that’s why we felt that the best path was inventing this no-code approach to getting access from any data field.

What are the most important parts of the company’s strategy over the next few years?

We are getting to the end of our full roadmap for the VennU data access platform. We have this powerful platform that is an enabler for automation, so we will move from platform development to partnerships with solution vendors.

HIStalk Interviews Guillaume Castel, CEO, PerfectServe

Guillaume Castel, MBA is CEO of PerfectServe.

Tell me about yourself and the company.

I have been CEO at PerfectServe for almost seven years. We have been working hard and making a lot of progress in driving value for our customers and our partners.

Almost seven years ago, we had a different vantage point on the constituents we serve, typically hospitals, health systems, and physician groups. Our commitment to them was that we were going to get the right communication workflows to the right people at the right time using the right channel. To accomplish all this, we went about acquiring and putting together four companies and then a fifth one.

If you fast-forward to today, we have more than doubled the size of our company. We are now 400-plus employees around the United States and Canada, along with some contractors outside the US. We have been deliberate about driving one big value proposition, which is accelerating speed-to-care across the continuum for all users and doing it from the cloud.

Doing all this the right way took some time. Integrating the pieces the right way took some time. But now we have a value proposition that resonates across diverse stakeholders in the United States, increasingly in Canada, and we are knee-deep in some really interesting conversations in Europe.

What does the clinical communication systems market look like, and how do EHR vendors fit in it?

We think of solving two reasonably evergreen problems. One is making sure that your workforce is optimized in the workplace and in the right place. Right people in the right place at the right time, clinicians and staff, to meet the demands of patients. Then once they are there, that they have an almost intuitive way of communicating and collaborating with one another. We are focused on those two big problems.

The second one leverages clinical communication capabilities. We have been ahead of the market in using logic, routing, and technologies to enable complex workflows for typically very large health systems. We partner with a ton of ecosystem vendors. We keep a catalog of 270 integration points with our competitors, with our friends, and obviously with the EHR companies.

I am proud to say that in many instances, we drive value with and for the EHRs with a number of our customers. Having this open-minded view of how to collaborate with clinical systems inside hospitals will continue to be important.

What metrics do health systems use to measure return on investment?

It has changed a lot. If you go back five to 10 years, it was throughput, length of stay, patient satisfaction, and physician and clinician productivity. Those metrics continue to be extraordinarily important for us to track. But now, what is always front and center on the minds of decision makers is clear and demonstrable ROI. 

We have put together a comprehensive platform that offers a lot of capabilities. Our conversation is, this is what we do at PerfectServe. Our Unite platform delivers value across the continuum for all of your users. We can help you with clinical communication issues. We can help you with provider scheduling issues. We can help you with your physician group and practice management issues. We are increasingly helping you with transfer center and operator console software issues. And last but certainly not least, we follow patients when they go home with well integrated patient and family communications.

This allows us to say, tell us what you are using today. Tell us all your scheduling systems across your various sites of care. Tell us about your pagers. Tell us about your sometimes point-to-point texting capabilities. Tell us about your old-school faxing capabilities. Tell about all the servers you have in the basement of your hospitals that are allowing you to power transfer centers.

We can rationalize all of that and drive almost immediate financial ROI for them. This has been a successful strategy for us. It does not exclude the clinical benefit that we drive, and we continue to be clinician-focused. But that immediate consolidation play with guaranteed financial ROI and tackling problems like physician and clinician burnout has been resonating for us in a way that we frankly did not fully anticipate five to seven years ago.

How is the industry looking at how provider scheduling impacts job satisfaction and burnout?

We continue to be surprised with the fact that there continues to be a need for fairness in how schedules are built. Fairness may be as simple as, “I don’t want to be on call three times this week,” or “I want to make sure that I can go attend my kid’s recital on Sunday. Therefore, take my preferences into account.”

Our technology allows administrators and sometimes physician leaders to make sure that all those preferences are taken into account when the schedule is being created, and that people feel that they have been heard. This concept of technology being leveraged to create fair and equal schedules, removing human bias and taking preferences into account, has led to health systems and large physician groups having higher retention rates with their clinicians over long periods of time.

We continue to refine that model. We make sure that when an administrator creates a schedule with our technology, it is a near-perfect schedule that requires as little human intervention as possible.

How are health systems and provider groups using technology to manage inbound communications?

It is going at a rapid pace. We are excited about solving, in partnership with some of our largest customers, this equation and algorithm for almost real-time alignment of patient-to-clinician supply and demand. You will see soon, and in fact a couple of instances are already live, the ability to flex the number of clinicians and support staff that you have in any given location based on the type of patients coming in and the acuity that they are presenting with.

That cannot be predicted six months ahead. You can build a really good schedule six months ahead, but day-to-day changes happen, and we need to be able to embrace that. Our technology is flexible and reflects near-realtime preferences. We can recalibrate who should be where and why.

It’s not as simple as saying that physician Guillaume is going to work from 8 to 4 in this location every Thursday. Sometimes it will be 7 to 3. Sometimes it will be 8 to 6. This alignment of supply and demand is paramount to the wellbeing and the financial health of all of our customers.

How has the role of contact centers changed?

This concept of a contact center is probably the least well-understood part of the hospital. It is the face of it. It is bidirectional. It is both outbound and inbound. It now requires vendors to be nimble with AI capabilities that support patients, their families, clinicians who call the hospital, and even ambulances that call the hospital with an important case that needs care teams to be mobilized in very short order.

The diversity of use cases that go through a transfer center or a contact center has changed a lot. We are proud to have a technology that powers that transfer center. When I think about the product that has driven the most momentum for us over the last couple of years, it’s probably that.

It’s this strategic control point, where you have agents who are trying to match incoming calls from a diverse set of stakeholders. It could be an ambulance, a patient, a family member, or a clinician calling from a physician group who is trying to get an update on their patients that have been admitted. We make sure that those agents can do their best work by having access to schedules and using proper routing and clinical communication to actually deliver a message that will get to the right person at the right time.

That is real innovation, real-time productivity, and true operational improvement for health systems. We are gaining a ton of momentum on that front, and we think that it’s a very big control point for the rest of our technologies.

How do you incorporate AI into your strategy and product roadmap?

We serve about a million users, and as such, we take our job seriously. We embrace AI, but we are also careful, because we cannot afford to make mistakes with models that are imperfect.

The way we think about AI at PerfectServe is twofold. One is internally, where we have embraced AI for the last two years. It has made us more productive. It has made us more efficient. It has made our people happier. There is no end in sight. We have appointed a person who runs AI across all programs at PerfectServe. We have a clear mission to make our company go faster.

Then you have AI applied to our capabilities that are customer-facing. A simple view that I believe is exactly right is that AI will help us get more out of workflow software by converting what was viewed as a workflow into actual work, enabled by agentic AI.

We have seen clear examples. If you are running a call center, you can definitely improve the experience by embracing AI at the first layer of triage levels so that the call gets to the right person in that transfer center, the right way, and with the right context. This is embracing AI in a way that makes an operational difference for the health system without putting at risk any of the clinical outcomes.

We are just starting there. We have a roadmap full of AI projects that are being applied to our work in the ambulatory setting, inside the operator console work that we do in health systems, and increasingly in our provider scheduling capabilities.

What are your lessons learned in leading the company so long and seeing it reach $100 million in annual recurring revenue?

Listen to customers. Invest in technologies that are differentiated, that can stand on their own, and that have real logic. We don’t invest in me-too products that are simple. We think that those will disappear fast.

Integrate your capabilities. Have an open mind to spending money to integrate with all the other vendors that hospitals and physician groups use. We will eventually prove to all of them that our products not only can integrate, but can also enhance the strategy they have already decided.

We had a breakthrough in 2022-2023 where we talked about putting together capabilities that had not been put together before. As recently as earlier this week, we see competitors following our strategy, and it makes us proud. We are focused on the next best thing that we will add to our roster of services and capabilities.

What makes me proudest is our people. We have more than 400 people who spend every day thinking about how they can make our customers better and how we can stitch together better solutions to drive value for them financially, operationally, and clinically. It has worked for us. We still have work to do, but it has been a great ride.

Have you seen challenged startups that might be ripe for acquisition that could help you expand your product?

We are super disciplined. The problem with the market right now is that there is a misalignment between startup valuation expectations and what we believe to be the actual embedded value in the asset that we are interested in. We look at four or five companies every week. When we find the right match between value, culture, and the people that are coming along with the technology, we will pull the trigger, and we will make sure that our customers are aligned with our strategy.

M&A is part of our strategy, and so is building new capabilities internally. We have a track record of doing that. The Healthcare Operator Console product is a good example.

If we pay attention to what our customers are telling us, and if we continue to have a mind pointed towards the future, we will put the right stuff together. That has worked well for us.

Consolidation of capabilities is only starting, and scale is going to matter. The track record is going to matter. Being secure for our customers and proving that every day is going to matter. Embracing AI, integrating, and making sure that we’re present for all stakeholders.

There’s a ton of momentum on the ambulatory side right now, with big multi-specialty groups that have clear enterprise-level software and AI needs. We are happy to be present there. We see very good synergies between those groups and the large health systems that we are lucky enough to have as partners.

We like our position. We work hard every day to make sure that we stay ahead. Research firms have been kind to us, and I think that we have earned it. Gartner has placed us at the top of the Magic Quadrant three years in a row, and we don’t take that lightly. We have had the same success with KLAS reports.

We are focused. We continue to pay attention to what the market is saying. We listen to our customers. We keep our culture. We believe that this is the right recipe for continued success.

HIStalk Interviews Nathalie McCaughley, President, Agfa HealthCare

Nathalie McCaughley, MA, MBA is president of Agfa HealthCare.

Tell me about yourself and the company.

I have 25 years in healthcare IT leadership roles, including 20 years with GE Healthcare globally. I have been with Agfa HealthCare for four years. I am French American and have been in the US for 23 years.

From a professional standpoint, I have held positions globally across pretty much all functions. I would describe myself as a growth leader who is focused on growing a business strategically, leading to tangible outcomes and a high potential to scale. Taking over businesses that are in need of new strategy and a new takeoff, which is exactly what happened with Agfa HealthCare.  

Agfa HealthCare is part of a broader group, Agfa-Gevaert. Our division is in a very different industry than the rest of the group. I was asked to take over the business in 2022, with the full mandate of the board and the group CEO to reshape the company and reposition it for growth, from both a financial and customer recognition standpoint.

How has enterprise imaging changed in the past five or 10 years, and what are its strongest areas of growth?

The healthcare industry has gone through a pretty intense era of consolidation among hospitals and outpatient centers. Over the past five or six years, we have seen an emergence of high-scale, very large health systems.

Everybody knows PACS, and enterprise imaging is often confused with PACS. PACS is a vertical, departmental-only solution. Enterprise imaging spans the entire health system across all “ologies.” When you connect this with the era of consolidation, where you have hospitals that are now health systems that are 10, 20, even 30 times the size, it becomes impossible to manage 30 different systems across the health system. The need arose to have a single, central platform to manage all imaging needs, such as storage and acquisition. That is enterprise imaging.

We come as a single solution, sitting over all of those individual PACS and managing the imaging health records for patients the same way an EMR is managing electronic medical records. We work alongside the EMR. That’s how enterprise imaging emerged from a needs standpoint. The consolidation and the scale of health systems is not slowing down due to financial and demographic reasons.

We anticipate, driven pretty clearly by those external factors, that enterprise imaging is not only here to stay, but will be the way that we work moving forward. That was the opportunity to bring a solution with strong relevance to healthcare and customer needs, plus an extensive runway to answer critical current and future challenges.

With that consolidation, how have expectations changed for being able to read images from any location on consumer-grade devices?

The bigger change in expectation is that you used to look at technology vendors. In the past, even our own company was selling an IT solution and software. This is no longer the case. We established and committed to being end user driven and clinician-first as a decision framework that guides our product design, cloud strategy, AI integration, and service delivery.

Technology is not meant to add complexity. It is not meant to be added work for a clinician. It is meant to make their life easier. Enterprise imaging adapts to the clinician and doesn’t force them to adapt to the technology. A true clinician-driven technology that is created for the clinician protects the clinical focus and confidence rather than competing with it. Everything has to be clinically driven, make an impact, make things easier, increase diagnostic accuracy, increase speed to diagnosis, and eventually serve patients. In the past, technology was separated from those priorities.

When a health system acquires a hospital, do they usually try to replace an existing system with a corporate standard?

They do it when they can. That is definitely a next step. Coexistence might be done at the beginning, but in the long term, it is not manageable and it is very costly. We have health systems that have more than 300 locations, which means that if everybody has their own system, they have as many IT teams, data server rooms, and so on. This is not sustainable from a management, security, and cost standpoint moving forward. Eventually, consolidation is required.

You are seeing it with Epic in the EMR world. We attach to Epic very well, but the number one startup discussion that we have with our customers is that they have 15 hospitals and 15 different paths. That doesn’t work, and they cannot afford this any more. Enterprise imaging comes in with standardization that creates efficiency not only financially, but from a productivity standpoint by simplifying processes. Backing the clinician first and improving workflows to benefit patient diagnostic and the speed to it.

How far along is the move to cloud and what possibilities does it offer?

I would refer again to demographic, financial, and operational factors. We talked about the consolidation of hospitals. Financial margin erosion is among the top three challenges for health systems. They see their margin eroding and they can no longer sustain what they were doing in the past, meaning acquiring an on-premise solution and maintaining a farm of servers in their back yard. The upfront investment was so substantial that it is no longer part of what they can do financially. They are challenged to do things better.

This has probably triggered not only cloud deployment, but also a subscription-based type of business with those health systems. Health systems are accelerating cloud adoption for a number of reasons, such as resilience, scalability, speed, and cost efficiency. We are focusing our strategy on being able to offer successful enterprise-wide cloud transformation with the right governance, security, and operational discipline.

How will you incorporate AI into your products?

AI is a big part of what we do. Workflow-embedded AI is critically important. We believe that it supports decision making without increasing the cognitive burden. AI is fully part of our solution, but fully embedded, not creating an additional click, an additional screen, or an additional platform.

This is how we see the growth of AI in enterprise imaging, as a fully embedded solution. The role of AI, at least in our space, is to enhance consistency, efficiency, and diagnostic confidence while keeping the clinician in control. The question we often hear is, will AI replace radiologists? No. This is not what we are doing. We are making things better. We are making them more productive, more accurate, and eliminating waste of effort, but keeping clinician in control.

AI will not replace radiologists. Radiologists will be replaced by radiologists who use AI. A health system may have 300 radiologists, and among that population, we’re seeing some that are resisting it and some that are embracing it. The future is made up of radiologists leveraging or using AI, not the other way.

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

We have been focusing on the clinician first, so security has become a big part of our innovation strategy. Enterprise imaging, in its native role, sits at the intersection of clinical care, data governance, and cybersecurity. A strong security and compliance framework enables innovation, cloud adoption, and AI integration in full confidence for our customers. 

When you adopt a software solution, the number one thing that you have to acquire from your customers is trust. We establish trust as a prerequisite for the long-term partnership with these health systems and healthcare organizations. It is foundational. As we’ve seen in the news, a cybersecurity event can bring down an entire ecosystem.

Our ability to develop the right partnership, being fully embedded in our customers’ strategy, is important. When you engage in a cloud transformation for enterprise imaging, for instance, this is not a one- or two-year journey. This is a long-term marriage. Developing those partnerships on the right foundation is critical.

We have seen the need for enterprise imaging and we are committed to it. What is truly unique about enterprise imaging is that compared to some other areas of healthcare, we are not a commodity. This is an existing need, a growing need. We are fully invested in rapidly increasing our clinical relevance as a solution for our health systems.

HIStalk Interviews David Emanuel, CEO, VectorCare

David Emanuel is founder and CEO of VectorCare.

Tell me about yourself and the company.

VectorCare is a patient logistics platform that manages services such as air ambulance, ground ambulance, and Uber and Lyft rides for patients, either inpatient or outpatient. Our core business is that we have no-code workflow to help move fast and get deep inside EHRs.

What are the major elements of patient logistics and what problems can you solve?

Think about discharge for a patient, where a nurse or a case manager is doing scheduling or coordinating that ride home for the patient. Historically, it’s done via phone and fax. Everything is pretty manual. EHRs aren’t designed for managing logistics the way that you would use Uber and Lyft today, so they are quite antiquated in that regard.

The problem that we solve is that at discharge, we make it easy for that case manager to schedule the transfer from inside the EHR and connect with their network of contracted vendors. Decision trees drive the right care at the right time. Not everybody needs a BLS transport. It might be a gurney. They can schedule that transport for the patient seamlessly.

What’s great is that it’s not just the scheduling part. We pre-populate data from Epic or any EHR, and once it is scheduled, you can see real-time updates of vehicle location. You can message directly with the crews through our messaging tools. We then capture all these relevant data points that help measure success and hold vendors accountable for how they perform.

We believe that the future is multi-event scheduling, so it’s not just scheduling the transport. A discharged patient may need to have a home health visit scheduled within 24 hours to reduce readmissions. Our platform automates that whole process. It finds the care team that will do the home visit as well as schedules the oxygen to be at the patient’s house when they get there. Those three major services help the patient’s care journey.

What benefits are customers seeking and realizing?

We have a large client in California that operates across eight states. It was taking them an average of 31 minutes to manually schedule an ambulance transport. We took it down to three minutes. There’s a huge ROI from keeping the workflow inside the EHR.

The second value proposition is getting the right care at the right time. Skilled nursing facilities shut down at 3:00. If you delay completing the discharge or scheduling the transport just by a few hours, they won’t accept a patient. That means that the patient has to stay over an extra night. That’s a cost to the healthcare system.

We reduce length of stay, improve time on task, and connect with a network of contracted vendors instead of non-contracted vendors that have different rates.

How much benefit do hospitals see from freeing up a bed earlier in the day when they might be in short supply?

Having access to a network of contracted vendors via a workflow that is embedded in the EHR, the patient record, provides a trickle-down effect. Quicker scheduling of that transport to take the patient to the right facility or home makes that bed available.

It also improves internal communication. Our platform allows for notifying the cleaning team that the bed is available so they can clean the room for the next patient. This is a huge value for hospital CFOs. They can track success. When did the patient arrive, when did they leave, and were they readmitted? We’re capturing all of these relevant data points to create an end-to-end view from a financial perspective for the healthcare system.

Are patients aware when the logistics process is inefficient? Does patient satisfaction improve when it goes better than expected?

It makes a huge difference in patient satisfaction. Recovery at home is far better than a recovery in a hospital. Getting them out quicker improves their quality of recovery. No one loves staying an extra night in a hospital unnecessarily. It’s a huge benefit for the patient.

How does your credential management system work?

It’s a key part of the vendor network that you have when you build out a marketplace on our platform. You are inviting all these vendors, which requires documenting that they have the right license and the right insurance to perform services for the hospital. Credentialing is a module within our onboarding process to make sure that the vendor is compliant and is credentialed correctly.

How do hospitals decide whether to establish a formal relationship with vendors, and if they do, which vendors to choose?

Big markets like California have a lot of saturation and lots of vendors competing, so you may have a large network of vendors that you’re working with. In smaller markets, you’ll have a one-to-one relationship. It varies from market to market.

What percentage of patients need some form of transport other than just a ride home?

From an inpatient perspective, a hospital with 300 beds is probably doing 30 transports a day where the patient goes home or is moved between facilities. Roughly 10% of their bed size. The logistic requirements are varied from high-acuity transport, so critical care transport all the way through a gurney van. In some cases, air ambulance, either rotary wing or fixed wing.

Outpatient is where the question becomes more relevant. Is the patient going to dialysis on a regular basis? Three trips a week involves six rides to be scheduled via a gurney, a Lyft or Uber, or some sort of sedan car service to get them there. That would be classified as an outpatient service. Or getting to your doctor’s appointment.

Even at discharge, you’re scheduling the patient’s ride to go home or to a skilled nursing center, but you also can schedule the outpatient rides to get them to that follow-up, such as a doctor’s appointment, chemotherapy, or to get their medication.

The benefit of our platform is that you can do both inpatient and outpatient, handling all of these nuances around the transportation needs as well as home health and DME needs as well.

Who typically pays for the logistics services that patients need?

If it’s not covered by insurance, the hospital or the patient will pay for the ride. We’ve built our platform where you determine medical necessity. That is customizable through our no-code workflow, because every state and every county is different. Once you know that it meets medical necessity and the insurance covers it, great. The ambulance provider, as an example, will bill the insurance. If it is not covered and it doesn’t meet medical necessity, someone has to bear that cost. In that scenario, it’s the healthcare system or the patient.

Hospitals are moving more towards covering the cost of the ride if it doesn’t meet medical necessity or isn’t covered by insurance. Freeing up that bed with the small cost of moving the patient out and getting them to a skilled nursing facility is cheaper than them staying for an extra night.

What level of EHR and workflow integration do providers expect when evaluating applications?

This is a layered question. I say that because healthcare systems, particularly CIOs and CTOs, have been given a mandate to move away from managing siloed systems that don’t talk to the EHR. They are managing many vulnerabilities in terms of different authentication approaches. That isn’t scaling very well for healthcare systems. Our objective is to bring all of these services inside the EHR and into the workflows. This is a lot for healthcare system IT teams to manage.

For vendors who are looking to get inside healthcare systems, win RFPs, and build a moat around their business, the beautiful part of our application is that you can build your own SMART on FHIR app, white label it with your branding, build your custom workflows with our no-code workflow, and put that inside the EHR. That’s a huge win for their customers, in terms of not having to move to a different system, log into a different application, or pick up the phone.

How do you position that capability within your overall business?

It’s still part of our core business. We offer our no-code workflow tools for web and mobile workflows and scheduling services already, so this is just another channel for us.

We’ve been building out these tools for over a decade. The next phase of our business was that we were building our own SMART on FHIR app and the tools that are needed to make it successful and do it really quickly. It’s an extension of our no-code workflow. We are building infrastructure. We’re not just an application. We’re building out the systems for everybody else to be successful.

What is your perception of the experience of using SMART on FHIR to integrate with Epic?

It’s complex. FHIR as a protocol has been slow to adopt, and SMART on FHIR allows you to have the right tooling to get inside the EHR.  If you don’t understand the complexities of that process and dealing with Epic, it can cost a lot of money. You have to maintain it and do security reviews. We have automated these things and baked that into our platform.

We saw the pain point in developing our own application. For our customers, this was a problem that needed solving. Once you are working with us, you’ll see how quick it is to build your own workflows and deploy into Epic. It’s remarkably quick because we’ve done all the heavy lifting, in terms of making sure that the infrastructure is there.

How do you expect to use AI?

We’ve thought long and hard about this, going back to before AI was even a thing. We were building out an agent, which we call ADI, automated dispatching intelligence. It is policy driven. It is primarily focused around automation and removing these manual processes that human beings were still doing on our application, like negotiating best times or prices. We’ve built a framework that will have agents handling different parts of the workflow. We’ve got good data in terms of what the future looks like and how this agent will be more embedded in our workflows.

We have deployed ADI over the last three years. Last year, we hit a record of saving over 100,000 hours just on using ADI for several of our large customers. The framework is there.

The huge win for us is that the way we build the SMART on FHIR application makes it agentic ready. In the future, you’ll be able to use the agents that we have inside the SMART on FHIR app to automate discharge for the patient, coordinate with the vendors, negotiate price, negotiate time, all while the nurse or the case manager carries on taking care of the patient.

Do hospitals still use discharge centers that give patients a place to wait for their ride instead of tying up a bed?

That’s still a thing in some hospitals. We work closely with some of our larger clients that have command centers or patient logistics centers. It’s like an air traffic tower, with patients coming in and patients going out being coordinated in one place. Our platform is so uniquely designed for solving that particular problem, because you can handle both inbound and outbound, or inpatient and outpatient, in one place and get full visibility across all these different services. 

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

SMART on FHIR will be key in a world of agentic workflows and having a framework for us to be able to make a difference in healthcare. We need to make sure that we do it really well. We are the go-to platform for vendors to build SMART on FHIR apps that get deeper inside the EHR. Speed, protecting your business, and winning hearts and minds are important. Being able to do that will be key for vendors.

HIStalk Interviews Theresa Meadows, RN, CIO in Residence, Symplr

Theresa Meadows, RN, MS is CIO in residence at Symplr.

Tell me about yourself and the company.

I have been in healthcare my entire career. I started as a nurse in cardiac transplant and interventional cardiology and ended up in IT by accident. Over the years, I’ve done various roles in consulting companies and software companies. Before Symplr, I was the chief information and digital officer at pediatric institution for 15 years, and with Ascension Health prior to that.

At Symplr, I’m excited because I get to do a unique new role as the CIO in residence. That means that I get to bring insider baseball to Symplr, meaning how healthcare CIOs think and the needs that healthcare institutions have. I get to help them with customers, building relationships, and doing the fun part of the CIO job, which is collaboration, building relationships and trust, and forming strategic directions. I’m excited about being here.

How do you define success in your job?

For me, it’s of course always having happy customers, meaning customers who are satisfied with the services and the software that we provide. That is how I would measure success. Hopefully being seen as a leader in the industry. Looking at our NPS scores and other ways to understand customer satisfaction, getting feedback, and making sure that we are listening. These are all ways that I evaluate how I’m helping the organization as the CIO.

How have you seen the CIO job change in the past few years, including the creation of new C-level roles that have a technology focus such as chief digital or chief transformation officer?

There has been tons of evolution. I can remember early on that the role was technology focused. We would spend a lot of time talking about product, functionality, uptime and downtime, and those types of things. 

With the transformation of going to the electronic health record and COVID even, we moved into more of an operational role. I saw my role become more about operations, understanding how hospital systems work, and providing solutions to challenging problems, versus being the technical leader. It has evolved over time to be a strategic position.

All those new C-level roles are important. How we partner with those roles is important. I don’t want to minimize the fact that a CIO can also be transformative. But having additional people who support a technology vision that can drive strategy and the technology that supports that strategy, the more people you have on board with that, the easier the CIO job becomes. We can have partners who are helping transform the organization.

Some clinicians in big health systems would argue that their level of burnout increased with EHR adoption because it was used as a corporate control mechanism rather than to improve their capabilities or patient outcomes. Will the rollout of AI empower clinicians or just be another way to enforce administrative rules and boost margins?

We have learned from our mistakes or sins of the past, if you might say, of how we collaborate with clinicians. With artificial intelligence, that collaboration is going to be critical. Only clinicians know if the AI is doing the right thing clinically. As we get into more and more clinical use cases, having those partners of nurses, physicians, and the whole clinical team to weigh in on how we know that the AI that we are using is safe, effective, and creating the outcomes that we need.

We learned a lot during COVID about burnout and how to start addressing it. Adding more to-do’s to clinicians’ plates is not going to be how we get there. We have to find ways to remove things from their plates and get them back to doing the things that they love, which is patient care, interacting with people, and creating good outcomes. I hope that AI will allow us to do that.

How will the tension be addressed between using these new tools to make the physician’s day better versus increasing patient loads, which would increase margin while shortening appointment lead times?

Ultimately, if we do the right things, productivity, revenue, and those types of things follow. If we can find ways to make our clinicians happier in what they’re doing and revamp the tasks that they are doing, I think we will see revenue improvements. We will see patient experience improvements, because people are happier in the roles that they’re doing versus thinking about it the other way, which is that we have to see more people. 

Most clinicians appreciate that the ability to get into health systems is difficult today. The average wait time is long. How can we see more patients and make our patients happier? If technology can support that, that would be ideal, but I don’t think that we can go into the conversation with the goal of seeing more patients. Our goal should be how to make the process more efficient, better for our patients, and better for the clinicians. The revenue returns will follow.

A recent KLAS report found that EHR issues, particularly duplicate and unnecessary documentation, influence nurse burnout. Could the flow sheet process be improved?

I agree with that. At my previous organization, we did the nursing collaborative through KLAS, and we saw exactly that. We have created the note bloat scenario in nursing. If we need to capture data for a quality project, we add more documentation. But we never take documentation away.

As we start adding things to the EHR, we need to be thoughtful about the purpose of that documentation and how will it be used. We spent a lot of time in my previous organization looking at and optimizing nursing documentation. A lot of duplicate documentation exists in flow sheets, and we overuse flow sheets to capture data that could be captured in other ways.

Health systems are rolling out AI without a strategy, governance, or regulatory guidance. Will they get burned or is this just the natural cycle of a new technology?

I think it’s probably the natural cycle of a new technology. We get excited about things that we hope will improve outcomes for our patients and our caregivers. We go at it hard initially because we think it’s going to change something. Then we realize that with every good technology, you have to consider the people in the process. AI is no different. 

The challenging thing with artificial intelligence is that we haven’t spent a lot of time looking at our data, our data structures, and what data will be used to generate those AI models. Healthcare has been notorious for collecting lots of data, but that doesn’t mean that it’s quality or good data.

The challenge that we as a healthcare industry have to figure out is how to get the right data into these tools so that we can see the appropriate outcomes. That’s where people start getting nervous about diving too deep into AI, because they know that the data that they are using may or may not be the most structured or clean data that they could be using to make decisions. You see most organizations focusing on that. How am I going to get the right data so that the model works the way it’s intended to work? 

How are health systems evaluating the use of AI? Are they emphasizing output rather than outcomes by focusing on revenue cycle and productivity that generates ROI?

I would love to say that the answer to that question is yes. We would love to see productivity benefits and ROI. But right now, we are still in that learning phase of what we are trying to improve. 

A lot of process improvement goes hand in hand with deploying AI, so a lot of learning is happening. Sometimes when we think we’ll see ROI, what we really learn is that the process that is driving the data is broken. To get a good outcome, save money, or do whatever we think the right thing is, we have to go back and reevaluate that workflow that we were doing as part of the process. 

AI helps us get us to that solution faster than in previous worlds, where we weren’t sure if it was workflow, the data, or the tool itself. AI helps us get to that decision-making process a lot faster, and then we can address those issues quicker.

Early technology such as EHR focused on technology that supported doctors since they are making the decisions that impact the bottom line. Will we see the emphasize refocus on the less-penetrated area of technology that supports nurses?

It is super exciting that we are now talking about the nursing profession and how to help nurses be more efficient and effective. The nurse is the center of all things when it comes to the patient interactions. Anything that can help automate nursing tasks through AI and assist with prioritization will be a win for nursing. 

Ambient listening for nursing will eventually be a huge win. The challenge with nurses is that we don’t typically talk about our assessments out loud with a patient, and we don’t talk about them in a way that would generate documentation. A lot of change management has to occur when we go to ambient listening for nursing. But once we figure some of those key words and phrases, nurses will adopt that quickly.

Nurses are resilient. If it’s a good process or a good product, they will adopt it. They adopt really crappy products sometimes and make them work. They are very resilient in that way.

We have an opportunity to look at nursing tasks, how we automate them, and how to give the tasks to the right person on the clinical team. Sometimes we give tasks to nurses that could be done by a nursing assistant, an MA, a unit secretary, or a unit clerk. There are ways to do that. AI can help with some of those workflow processes and getting the right task to the right mailbox.

A lot of opportunity still exists in the space between the EHR and the ERP. Hundreds of applications haven’t been optimized or looked at, and those are all falling in the operations space. There is also an opportunity to improve those processes where we haven’t spent a lot of time yet. There’s a whole vast array of applications, workflows, and processes that the EHR or the ERP doesn’t touch. There’s plenty of opportunity in those areas for the future as well.

Will nurses need to vocalize or dictate what they’re doing to support ambient listening, unlike physicians who can mostly carry on normal patient conversations and let AI do the work?

For physicians, it’s natural. They dictate it all the time through their whole career. That’s been their process. 

For nurses, when we talk to patients, we are trying to do the education piece and less the documentation piece. It’s going to be training a nurse on how to say some of the key findings that they ordinarily would just document or check a box and then educate a patient, building that into the education. Talking to the nurses and figuring out that style. 

The change management pieces are going to be something different for nursing because we focus a lot on education and making sure the family or the patient knows what the next right step is, versus talking about the assessment out loud.

How will virtual nursing programs affect nurse shortages?

Virtual nursing is a huge win. I am a huge proponent for virtual nursing for a number of reasons. The first is that we can capitalize on nurses who may be ready to retire later in their career, where the physical part of nursing is hard, but the intellectual process is still intact for them. Virtual nursing allows us to have some of our more seasoned nurses be able to help some of the newer nurses by being there virtually for them as a resource, to watch things on the unit, and to see how things are going and give input. 

It is also a good tool for addressing burnout, because you can create schedules to have people rotate through virtual nursing so that they aren’t at the bedside every day. They can rotate through those different scenarios and learn a different skill set. 

It’s better overall for patient care, because you have people who are observing what’s going on in each patient room, and you don’t have that today. Some of the safety events that have occurred can be mitigated through a virtual nursing process. There’s lots of opportunity to reduce handoffs and reduce the need to have two nurses in a room for certain processes.

There’s a lot we can still learn from that process since people are pretty early on in their deployments of virtual nursing. We probably haven’t seen all the benefits that can be accomplished through those programs just yet, but we will.

Medicaid cutbacks, the elimination of subsidies for exchange-sold health insurance, and the possibility of having more unemployed people who lose access to employer-provided insurance will likely raise the number of uninsured people. Are health systems planning for that, and do technology implications exist?

Health systems are absolutely planning for that. By nature, we are conservative beasts. If we start to see where there will  be a challenge around funding, insurance, or people’s capacity to pay for medical care, we get more conservative. 

Our choices around technology will be to look for items that will improve revenue capture, make our length of stay shorter so the cost is cheaper, and look at ways to be more cost effective and see more patients. We are going to be looking for those types of things, but we’re also going to be looking for ways that we might lessen the burden with more virtual care, remote care, where you’re not spending the large dollars on an inpatient stay. If we can take care of people remotely or hospital at home, organizations will look at those avenues, because the cost inevitably is cheaper in those scenarios. 

How we maximize the resources that we have to deliver to the care at the lowest cost point is going to continue to be a focus for all organizations going forward, especially if we have a lot of cutbacks in insurance capabilities.

How do  you expect healthcare and health technology to change over the next few years?

We will see people focus on ways to automate the workforce and automate having the right people on shift at the right time for the lowest cost. You will continue to see a lot of focus there.

We will also start to look at ways to augment our workforce. We will always need nurses, doctors, clinicians, and people, but how do we make them more efficient so we can do more with less? Automation should help us in those areas.

We will continue to see how we can educate the next set of providers, nurses, and other clinicians so they come out of school much more efficient using tools better. 

There’s just a lot that we can do, and we will see this evolve. I get excited, because having done this for the last 25 years, the technology has finally caught up with the workflow things that we need. We will start to see advances more rapidly than we’ve ever seen.  I’m excited about the things that we will be able to do in the future with where technology is today.

HIStalk Interviews Kevin Phillips, Business Category Leader, Philips Capsule

Kevin Phillips, MBA is business category leader of acute care informatics with Philips Capsule.

Tell me about yourself and the company.

I joined Philips in 2021 through the acquisition of Capsule. I’ve been with the company for 16 years.

Now more than ever, we have an opportunity to make an impact on improving how clinicians can more effectively care for their patients and reduce the tedious elements of documentation, the steps to find information, and the need to react to details, all to allow making faster and more informed decisions.

How does the former Capsule Technologie business fit into the healthcare strategy of Philips?

It’s clear for us that to support the move toward virtual care, to remove some of the manual repetitive tasks for the frontline care team, we need to find ways to arm clinicians remotely to support and assist that frontline care team. It all starts with how we harness the live data that is connected to all of those devices around that patient bedside,

We started, decades ago, with how we automate data for use in medical device integration to the EMR. That has now expanded to, how do we leverage that same data and transform that into actionable insights in a host of different locations? It could be within the central station at the nursing center station. It could be at centralized virtual care centers. It could even be at the mobile handset of that care team. They can now start to manage their patients really anywhere.

It started with the observation that live streaming data is a critical resource for moving from reactive to proactive care.

Once all of that data became available and the opportunities to analyze it became obvious, how did it shake out whether that would be done a company like yours or the EHR vendors themselves?

If we look back over the past 25 years, medical device integration was once a Class Two medical device. Most EMR companies have historically shied away from moving into the medical device realm. Also, connecting to these devices requires at times hardware connectivity such as hubs and unique cabling that gets deployed in the room.

For those two reasons, while a few EMRs have moved in that direction, it was a logical place for a dedicated entity to focus. Philips, as a leader in patient monitoring, said, we have the capabilities to connect to all these devices in the room. Not just manage them for getting data into the EMR, because less than 1% of that data makes its way into that patient record, but to leverage all of that data for more proactive use cases as well. Other use cases around full disclosure databases, where you can dive into risk initiatives or leverage things for alarming and alerting as well.

Moving more and more into this regulated space is why EMRs haven’t dipped their toes fully into the space today.

What is the value of that other 99% of data that EHR vendors don’t use?

In most charting systems, you’ll typically chart every one to 15 minutes. The key element is that there needs to be a clinical validation step. That’s why they’re not doing it in more routine fashion.

What is missed when you capture only a snapshot of that data is alarms, waveforms, and device settings that provide comprehensive but subtle insights in patient care, such as the physiology of that patient and the status of devices. If you start to understand those subtleties, can new insights be brought? How can we, through partnerships where these same questions are being asked, better leverage all of that data to leverage some insights as well?

What kind of device monitoring do you do?

One example is the different modes of a ventilator. The data is critical for a respiratory therapist to understand the state of the respiratory care for that patient.  Those sorts of elements give additional context to not just the device, such as ventilators, but if we look at all the devices that are surrounding that patient and capture all of that together, you can have a richer view of that patient.

There are also scenarios of failure modes for devices or sensors falling off. Understanding those alarms or states can give additional clues around how somebody who responds to those alerts remotely, or who provides secondary oversight, can tell the bedside care team or the remote care technician how to effectively manage that patient and how to manage the devices in that room. That’s why even the device settings are of critical importance in many situations.

How much of the company’s strategy is driven by data needs that didn’t exist or weren’t possible a few years ago, such as clinical surveillance, virtual care, and real-time analytics?

Most of our investments are toward moving us into that direction. We’ve invested significantly in the data model of all the drivers that are communicating to each of these medical devices to truly support this semantic interoperability where waveforms, alarms, and device settings can be liberated and ubiquitously understood by all endpoints.

Secondly, we are seeing this move towards flexible, centralized monitoring units. Remote virtualization, where patients may not move from one care setting to another, but the technology does and the care team moves and adjusts with them. To do that, we needed to find ways that we deploy this data management backbone so that data can be leveraged. But also tools, applications, holistic viewers, and the ability to alert assigned care teams to changes in that status.

The technology now supports these new care models. But there’s also this collaboration with our clinical services team and clients that help understand their objectives are and how we can help them change how care is delivered from that in-person to remote virtual care location as well.

Is the level of EHR integration as deep as you need? Does the EHR need to follow you along as you come up with new concepts of how the data you capture can be used on their side?

Yes, but I would say that sometimes the EHRs get maligned with “they’re not interoperable” and “they won’t share data.” We share a lot of the data that we capture from devices. The context around the ADT, labs, and patient history is fairly easily obtained from the EMR. 

This relevant context, when paired with live data, that deliver this additional insight. A lot of the research and partnerships that we have with key academic hospitals like MGB are allowing us to identify these observations and then deliver those insights back into production.

I find the EMRs to be actually quite collaborative in this. For the clinicians, these are contextually launched within EMRs. It’s actually a quite collaborative process across the board.

What opportunities does AI present?

We have used machine learning techniques to help us build a variety of our algorithms that are deployed in our solutions today. We’re also seeing that new agentic AI helps us streamline mapping that we use within our drivers, obviously with human validation at the back end.

We also have many different reporting, retrospective reporting solutions. We have surveillance tools where you can see alarm events trends, but sometimes you just want to ask a simple question about what has happened. These are areas where generative AI and assistants can be deployed in these tools. We are continuing to explore that area and drive it into the solutions moving forward.

Agentic AI will allow us to reason with the data and eventually  integrate video over time. We can reduce and streamline unnecessary workflow steps. That is just fascinating. In all aspects of our life, we are evaluating how AI can reduce the number of steps to get certain activities completed. That’s no different than what we are trying to accomplish within Philips as well.

What factors will be most important to your business strategy over the next few years?

We have seen tremendous advancements in technology. But we have to co-create with hospitals to identify how we can support clinical adoption and change workflows. Activating virtual nursing, virtual observation, and virtual surveillance use cases requires a shift in the activities that are done at the bedside, which activities are done virtually, and how that collaboration occurs. There is certainly a big push and a need to move towards that. But we have to figure out how we continue to collaborate with our health systems to maximize and streamline that workforce.

There is also the reimbursement landscape and the regulatory landscape around deploying AI into solutions and medical devices. We expect to see additional guidance from the FDA. How can we identify the best pathway to introduce this new technology in a safe and effective way? That’s always our core focus.

We could focus on a million different use cases. Our focus is to co-create with specific leading health systems and work backwards from highly impactful use cases. 

If we do these things, our investments will have a global impact with the clients who use our solutions.

HIStalk Interviews James Lakes, President, Mednition

James Lakes, MSc is president of Mednition.

Tell me about yourself and the company.

Mednition works with healthcare leaders and providers who are looking to improve the clinical, financial, and operational performance of their emergency departments. The ED is the front door for about 40% and up to 60% of all their inpatient volume.

We believe in the concept of catching things early, whether that be high-risk conditions or sepsis. Catching the problem early, putting people on the right care track, and then leading to better outcomes from clinical, operational, and financial standpoints.

I spent almost 30 years of my career working in health IT, primarily at big platform companies like Microsoft, VMware, and Salesforce. Over the last four or five years, I’ve focused more on startups, which led me to Mednition.

How is AI for nurses and operations philosophically different from physician-focused AI?

No ill intent towards any of our clinical leaders, but when we’re investing in innovation, in the provider space in particular, the focus is typically physicians. These are your highest-cost employees. They have high benefit, whether that be thoracic surgeons or orthopedic surgeons.

We often see that because EDs have traditionally been considered a loss or cost center for most providers, there hasn’t been a lot of investment in innovation for ED nurses and ED departments in general. The nurses in triage ED are the first people to meet and assess the patient. Helping them get more accurate within their acuity setting to send them on a path with providers leads to better outcomes across the board.

Upwards of 55% to 60% of clinical staff are nurses. We believe that helping them is just as important as helping physicians.

How do nurses choose that path or make triage decisions?

We based our software on the ESI model, the Emergency Severity Index, which is sponsored and built by the Emergency Nurses Association. This is a scale from one to five, five being the least sensitive or least urgent, with one being the most urgent. About 85% of all ED nurses in the country are trained on that model. We based our model on that, and we have a deep research partnership with ENA to improve our model to make sure that we’re taking best practice into consideration.

Nurses spend more time with patients and have intuition about outcomes that aren’t found in charts. How do you incorporate that?

A nurse has two to four minutes in that triage moment with the patient. They are interviewing, getting their primary complaint, taking their vitals, and observing that patient to make a decision on what care path this individual should be on. In that time, they interview you and observe you, but they really don’t have time to check all of your clinical history, the accuracy of what you tell them about the medications you take, or what conditions you have had previously.

Our product is called Kate, which is the name of the daughter of one of our co-founders. She showed up in ED with an inaccurate acuity setting and was in serious condition. She survived and is now a young adult. The founders wanted to prevent other families from going through that.

Kate  goes to work in the background. The nurse does their observation. They set their acuity setting. Kate looks at the patient’s health, their history, their medication lists, all those things. She compares that to millions of cases in our model and comes back with an acuity setting only if she differs with the nurse. If not, she doesn’t send anything, which means that she’s not disturbing the nurse unnecessarily.

The only time the acuity does not matter is when Kate suspects sepsis. Then she will automatically send an alert regardless of the acuity setting of the nurse. Sepsis is the biggest killer in hospital settings and testing, getting antibiotics in them, and acting quickly, leads to better outcomes. That time to action is important.

Executives in some health systems influence software decisions more than frontline clinicians. How do you sell the product?

Like any startup, you work early on product-market fit. Next you figure out what your target audience is.

We know, and can see in our engagements, that ED nurses who are on the front line, their managers, and their directors are our biggest champions. However, often they are not the ones who make the final decision or have the budget. We understand the nurses deeply and work with them collaboratively to take that to their leadership. We highlight the issues, how Kate addresses them, and then build the case for the ROI from a clinical, operations, and finance perspective to justify the investment.

We’re getting better and better at it. The nurses are getting better and better at advocating for themselves with our support. But we do see that it’s a broad stakeholder sales engagement. It requires having champions at the front lines, but then making sure that the leaders at the top who are making the decisions where those critical investments go are aware of the impact of Kate.

What is the value proposition that you present to the CEO, CFO, or CIO?

I’ll use an example of a provider that we worked with recently. Within six months of going live, Kate actually paid for herself. They tracked  a number of metrics. One was left without being seen. Patients who show up in the ED will leave if they wait too long, and that can lead to worse outcomes. The might have to come back, or it could be lost revenue because they go someplace else.

Length of stay is also a big issue. This organization was able to not only lower their left without being seen rate by 1%, but also lowered their length of stay by 23 minutes in less than six months.

On the financial side, because they had better accuracy and better documentation, they saw $400,000 of additional financial revenue because they had fewer down charges and fewer denials from payers.

How well do health systems integrate what happens in the ED with opportunities for long-term patient engagement or revenue generation?

The market is getting better at recognizing the value of getting things right at your front door and the downstream impact of that. It’s definitely a shift in mindset and a shift in focus.

How does Kate integrate with other health system platforms?

We integrate with the EHR, specifically Epic and Cerner. We are working on a couple of others, such as Meditech and Medhost.

The good thing about Kate is that she’s working in the background. She alerts or notifies nurses only when she has to. It’s  not obtrusive to them. We talk a lot about alert fatigue for clinicians. We have made it a distinct focus of our company to not be a notification alert problem for our clinicians.

How much evidence or background do you provide along with the recommendation?

Kate provides a message. The nurse says it’s a three, Kate thinks it’s a two, and she delivers why she believes it’s a two. The nurse then has the option. We don’t make the decision for the nurses. They have the option to change the acuity setting to a two.

Typically when they do that, it’s because Kate has identified something they may have missed, or they may have made an error. Then they correct that error or they improve the documentation when they do the up-triage, as we call it, that then drives the decision, which leads to better outcomes downstream.

When they don’t act, they typically document why, which leads to feedback to us. We have a clinical team of physicians and nurses, some of the top in the space, who review those cases and feedback from the nurses. We use that to generate cases and continuously improve our model.

Having come from big tech companies, what are their advantages and disadvantages in their involvement with health technology?

Those companies have incredible R&D teams, incredible market reach, and incredible flexibility in those platforms that provide a tremendous amount of value. But when you start to get down into deeply research-oriented, specific use cases, the specific clinical decision support, they will struggle, because they are trying to build a big platform to then fit into various scenarios in healthcare. Whereas when you’re a startup and you’re focused on that specific problem, you can get very, very good at it.

I’m a former athlete. It’s like thinking about Steph Curry. He’s a marksman, maybe the best marksman we’ve ever seen. He’s a specialist. He’s deeply talented at that one thing. If I tried to make him an all-around player where he was going to be the best defender, the best rebounder, the best passer, and all those other things, he may not be able to be world class across all them all. I might dilute his talent. It doesn’t mean that there aren’t any players that can do that, Michael Jordan being one of them, but there aren’t many, and that’s why they stand out.

If I have a person, system, or solution that is really targeted and can be world class at that, that is the benefit of the startups. The platform companies can bring broader value across broader spectrums, but they may not be as specific as you need for things like sepsis identification or triage acuity.

What is the present state of the healthcare buying market from the viewpoint of a startup that is trying to scale, and how will it look in a year or two?

We’re all concerned about what will happen with changes in Medicaid and any reductions in Medicare expenditures. What does it mean? In our particular space of EDs, a recent Vizient report says that they anticipate higher volumes in the ED because more and more people who lose coverage will use the ED as a form of primary care. When they use that as primary care, they typically wait until their state is dire or even worse. Acuity and severity will become more difficult and intense for our EDs.

If you have increasing volume and increasingly complex cases, it becomes a recipe for potential chaos in our EDs. We are hoping to help them alleviate some of that by being proactive with something like Kate.

What is the company’s strategy over the next three or four years?

We will have a sepsis breakthrough designation for our Kate sepsis model in early 2026. We are submitting for final approval from the FDA. We hope to have that by the end of Q1. I think we will be the only software product with FDA approval for sepsis early detection.

We are including more and more models. We have a partnership with a leading children’s hospital and research center for building triage models for people under one year old. We are working all the way down to infants, both for triage and sepsis.

Another model that we’re working on is continuous monitoring for sepsis post-triage. You’ll see some of that come out in early 2026.

We will continue to add models. Our focus will primarily be early detection of any high-risk patient condition.

The biggest thing is being an advocate for our ED departments and the ED leaders out there, They are sometimes not the first line of thought for for our healthcare leaders. If you talk to a CEO of the health system, they can often tell you who all the cardiac thoracic surgeons are and who their family members are, because that’s a high revenue focus area for them. But if you bring that attention to their ED leaders or ED departments, that’s not their focus and they don’t have that same familiarity. We  try to be an advocate for that space because that front line sometimes gets forgotten.

HIStalk Interviews David Lareau, CEO, Medicomp Systems

David Lareau is CEO of Medicomp Systems.

Tell me about yourself and the company.

I have been with Medicomp for a number of years. Our core competence is that we produce a clinical data engine that we call a Clinical Knowledge Graph. We’ve been building it based on expert input since 1978.

We have been through many technology transitions. Now we’re in the world of AI with clinical applications. We feel that we are well positioned in that area since we have very domain-specific knowledge for training small models to do what we need them to do.  

Will the customer cost of using AI technology that is sold by big tech firms that have to keep investors happy going to inevitably increase?

We think that the Butcher’s Bill is going to come in for these large models that are expensive to use. People already are starting to say, “We are going to use AI to train for specific workflow issues and specific clinical domain issues.” We believe right now that we are well positioned in that space.

We are having great success in terms of performance and lower cost by using a small model rather than a large model. Our engine, and all the power that’s in it, can be run on CPUs rather than GPUs, inside a vendor’s own security environment without going out there. We can do that because we have a target of 400,000 clinical concepts with hundreds of millions of links for diagnostic relevancy and coding relevancy. To be able to do that with a small model is because we have a clinical target that’s been very well-defined over the last 40-some years. 

The vendors that we are working with have seen their costs drop by using a smaller domain-specific model that is trained on our clinical data points that link to our engine. The roadblock to that was the lack of a clear standard for how to communicate between applications using various aspects of AI. The MCP, or Model Context Protocol, developing as a standard has allowed us to expand the number of partners that might be able to take advantage of our unique Clinical Knowledge Graph.

That’s why what’s happening in the industry is an opportunity for us rather than a threat. If I want to know the 250 clinical concepts that might be relevant for somebody with chronic kidney disease, that’s in our engine. The MCP allows us to present a standardized way to request that information from our engine and send it back to the application, whether it’s a language model or somebody else that wants that information. It will be what drives the integration of all these AI agents that people are building.

It was an essential, missing building block for communications between systems that are using AI to do very specific tasks. When Epic, for instance, announces that they’re building hundreds of AI agents, they will be using things like MCP to communicate between various aspects of their system.

Has AI changed your business strategy?

It has. We definitely have had to adapt to it. The conversational AI still captures text. It does a very good job at it. We’re really astonished and pleased at how effective it is at removing the need to enter text into a medical record. But it’s still text.

We have been using AI. We’ve been using language models internally to fine tune our offerings and our tools. We are building a small model, domain-specific, task-specific ways to use our data, extract data from text, and then operate on it to service all the downstream things that you have to do, like quality measures, adequacy of documentation for Medicare’s Hierarchical Condition Categories, that sort of thing. We’ve had to embrace it and figure out how to use it transparently, effectively, and affordably in the clinical domain. 

It is an exciting time as the AI tools have matured, the power has matured, and you have everybody in the industry rowing in the same direction. But they need clinically specific tools to get where they need to to make it affordable and useful at the point of care.

We saw it as more of a threat two or three years ago. A threat being anything that causes people to not need to do business with you today is a competitive threat. When the frenzy over AI started a few years ago and really built lately, it really was a competitive threat to us because it made people sit on the sidelines and wait to let AI figure it out. Now people are realizing that generalized predictive pre-trained transformer is not enough for clinically specific work. That’s where we are hooking it into our Quippe Clinical Knowledge Graph to do very specific things for clinicians. People are realizing the proper uses of AI in clinical medicine and the things that it doesn’t do so well.

We are pleased with the way things have developed over the last 12 months, as the rubber is starting to meet the road with AI in medicine.

Startups and big tech companies might be slow to realize that AI and ambient documentation are table stakes that aren’t much of a business moat. Does your phone ring from companies that have the technology but need help understanding how to integrate it into healthcare workflows?

I get four or five inquiries a week. Most people that call when they hear the specificity of what we’re doing say, “We’re not quite to that point yet. We’re just trying to figure out how to compete with all the other people that are in our space.”

We’re starting to see that people are actually putting these applications into use. Those are the more serious inquiries when calling us. They say, “We’ve got the table stakes working, but now we’re having trouble meeting all the downstream requirements because we just have text, we don’t have data.” They need to get there because when the government puts in very specific requirements for things like quality measures. They are looking for specific data points. That’s what’s in our engine.

They say, “The acquisition of documentation is no longer an issue. Now we need to do something with all the downstream processes that are tied to the information in that text.” When they hit that wall, that’s when they’re calling us.

You wrote something about instafraud, the claim by insurers that some providers are using AI to increase billing, and their intention to use AI to stop it.

We’re in initial conversations with some folks in compliance and regulation. One example where it shows up is in Medicare Advantage, which was supposed to reduce the cost of caring for people people in Medicare. It uses risk adjustment codes, Hierarchical Condition Categories, to identify somebody who has a disease that puts them at risk of poorer outcomes, and then to manage those conditions. But to do that, you have to code a diagnosis to get that risk, and then receive more money put in your risk pool each year. 

AI was algorithms even before AI became a thing. People were using algorithms to say, “This guy has a high creatinine. He probably has chronic kidney disease, so let’s code that.” If you code it and send it, you get a higher risk score, but the documentation has to support it. 

When we published our E&M algorithms when the 1997 guidelines first came out, the most common question we got was, “You guys have all this data that can support a code. Could you use it to tell us the three things we need to do to get a higher level of service to get more money?“ We said that we could, but the government has seen what we’re doing and warned us off and said, “If you do that, we’re going to come after you.” So that feature was disabled. You can’t ask it the minimum you needed to document to get a higher code.

The same thing started to happen about five years ago with risk adjustment. They called it “suspecting.” They wanted to use AI to look at the record and find potential evidence for one of these HCCs that would support a higher code. This would be submitted without necessarily seeing that the documentation supported that the patient actually had that condition.

Suspecting is a valid thing if there is a condition that’s unaddressed and you then address it, but it’s fraud if you look for the possibility that somebody has something and then code that they have it without investigating whether they actually do.

There’s a tug-of-war going on between the payers, the regulators, and the enterprises over the proper handling of patients with chronic conditions in the Medicare Advantage program. The government is starting to pay a lot of attention to that because Medicare Advantage was supposed to cost less per patient than traditional Medicare fee-for-service and that hasn’t turned out to be the case. I think it’s because people are over-coding for risk factors.

How does Epic’s public sharing of its AI roadmap affect innovation?

There are a number of layers to that question. Epic is not the only large vendor that I would call an impediment to innovation just because they’re a dominant in their space. We do quite a bit of business in Asia, and this is not limited to the United States.

Years ago, we had another unnamed vendor in the US, not Epic, whose customers told them, “We really like what this niche vendor is supplying. I want it.“ We had the experience with a different vendor years ago, where they said, “We’re getting a lot of customers that are asking for what you have. We’re probably going to develop that ourselves so we’re not interested, but we are willing to work with you. But since we think of our customers as an asset, you’re going to have to pay us the bulk of your revenue for access to that asset.”

That’s the moment where I realized that dominant vendors, because this vendor was large in the space then, tend to treat their customer as an asset and as turf that they own, not as an obligation to provide a higher level of service. When vendor app store organizations were first set up, the agreement that you had to sign as a niche vendor said, “We need to vet what you have. You need to show it to us. You need to show us your source code so that we can make sure it doesn’t create any vulnerabilities on our system. But if we then decide to do something like that ourselves, you have no recourse to us.”  That scares off the niche vendors.

We’ve also had the situation where a large consulting company that specializes in implementations for the large HISs said, “We have a lot of customers asking for what you have. We have a lot of people asking for the kinds of things that you and other companies like yours provide. But we also have $90 million a year in consulting revenue from this vendor for implementation assistance, and they’ve told us that we’re putting that at risk if we start to introduce these niche best-of-breed vendors into their ecosystem.” So it really does stifle innovation in that sense.

Do companies call you wanting to buy Medicomp rather than try to build complex healthcare technology?

Yes, we get that from investors, private equity, and larger vendors. The issue for us is that we do one thing. We focus on it. We don’t do anything else. Being employee owned, basically, allows us to focus on what we do and not get distracted, and we plan to keep doing that.

As people see how you can leverage our Clinical Knowledge Graph for a very specific thing that has a widespread need, we get a lot of activity. I thank people very politely and explain that we see a model of sustaining what we’re doing for quite a while, even into the next generation of the company.

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

We need to make certain that we are using these new AI tools to make ourselves more productive while producing our Clinical Knowledge Graph. With the new Model Context Protocol, MCP, stuff that is coming out, we’ve been API based for a long time. We make it easy and transparent to link to our clinically data specific APIs to accomplish specific tasks. Acquiring documentation, no longer a problem. Acting upon it and doing something with it is the next step.

Our strategy over the next three to four months is that some EHR vendors will start showing the intersection between ambient listening coming in as documentation, then link to our engine that will validate, filter, and present that information and accomplish all the specific things that you have to do with the data, such as getting the right billing codes, meeting the quality measures, and verifying adequacy of documentation for HCCs. Linking our stuff and allowing our engine to be accessed through the MCPs to accomplish specific tasks other than just documentation.

We see great potential in that space. We will have the first few implementations of that hitting the market over the next few months with some specialty-specific EHR vendors.

HIStalk Interviews William Cavanaugh, CEO, Concord Technologies

William Cavanaugh, MBA is CEO of Concord Technologies.

Tell me about yourself and the company.

I’ve been in technology for over 30 years and health tech for 20. I’ve worn just about every hat there is to wear in a healthcare technology company, from making the coffee, developing the software, taking out the trash, closing the deals, and writing the business.

The high-level mission of Concord Technologies is to advance healthcare through universal exchange and intelligent processing of data. We leverage advanced AI to drive a smarter, faster, and more connected healthcare ecosystem.

What kinds of documents do health systems receive and what challenges do they experience in processing them?

The big challenge in healthcare is the exchange of data between disparate healthcare entities. You have to look at the volume of data. There are 2.3 zettabytes of data generated every year across healthcare. What’s a zettabyte? I can tell you that it’s a billion gigabytes, but that doesn’t really represent the challenge.

If you look at one hospital to paint the picture, one hospital creates 50 petabytes every year. Again, that is difficult to comprehend. Picture yourself in an NFL stadium, in the upper bowl. If you printed the physical equivalent of the annual data from just one average hospital, it would fill 750 NFL stadiums to the brim, and it is growing at 36% a year.

Now you need to share that data. You can’t email it to a doctor because it will go to junk or spam. You need a secure, ubiquitous way of sharing that data. Everyone thinks that the big EHR vendors are going to solve the problem, but there are 500 EHR vendors. They are also not the only player when you add in radiology information, PACS, payers, and pharma. There are thousands of different systems.

On the entity side, the US has 6,000 hospitals, but the number blooms over 200,000 disparate entities and growing when you add in post-acute, outpatient, private practices, urgent cares, specialty practices, et cetera. The problem that we are solving spans 200,000 disparate entities, 1,000 software vendors, 2.3 zettabytes of data growing at 36% a year, and you need to share data.

The space that we play in is documents. Think about documents between your payer, pharmacist, EHR, specialty, and primary. Our very large customers do big volumes. We do about 22 million pages a day through our network. Our big customers do over 50 million documents a month. One of our big EHRs does 90 million a month. We bring that data through an exchange protocol, universal protocol, and then we like to say that we bring it to life. We classify the document, extract key pieces of information, and then insert it into the systems that we’re on.

People might think of interoperability as a FHIR-based data exchange. How does that approach coexist with how documents are managed?

I always say that we’re not in the fax business. But at 10,000 feet, we are a fax company, even though we don’t use paper and fax machines. We use the digital fax protocol to exchange these documents.

FHIR has been around for a long time, plus HL7, integration engines, QHINs, and HIEs are trying to create the structured data exchange. We keep it simple. You have a phone number, and from any EHR, you click “send document.” If MD Anderson wants to send a document to Debbie’s Dermatology in Rice Lake, Minnesota from the EHR, they click “send document” and Debbie’s Dermatology, if she has a fax number, receives a document. Then it automatically sends a response back to the referring physician at MD Anderson that the document was received.

That’s what we do very simply, but we don’t stop there. Your big dermatology clinic gets 5,000 documents in a month. What is this document? We classify it. Then a dermatology clinic is looking for different pieces of information in that 50-page chart that just came across and that a urology clinic would be looking at. We extract the pieces of information, leveraging AI, that are relevant to the receiver of the document. That’s where we bring it to life.

Fax gets a bad rep in the market. I almost didn’t take this job as CEO because I heard we were a fax company, but we’re in the digital exchange business, using a universal protocol.

You asked about FHIR, though. There are instances where FHIR comes into play. We use FHIR to do a lookup to find that patient in Debbie’s Dermatology to match it so we can insert into the system a record. Then we use HL7, which has been around for 15 to 20-plus years as well.

The mental picture of faxing is someone watching thermal paper spool off a fax machine that is covered by taped-on “send” numbers. Is healthcare the only industry where faxing is still a viable way to exchange information?

When you say fax, you think of the curly paper, and if you’re as old as I am, the dial tone. That’s not the business we’re in.

We had a third party do some market research and I’m still surprised by the number of fax machines and paper faxing that is still done in healthcare. Anywhere from at least 10% to 15% of the documents still go through that old-fashioned, corded phone protocol.

Other entities also use fax, both digital and old-fashioned fax. Legal still uses it to fax documents. Payers, the FBI, and the IRS still use it. Other big government entities and institutions, along with mortgage companies, use old-fashioned fax. They’re also migrating to digital fax.

There is still that need when you want a secure ubiquitous protocol to send and receive documents where email doesn’t work, and that fax protocol is still used outside of healthcare. But I would say that around 70% of the digital document exchange via that fax protocol is within healthcare.

How does the process change in moving to digital fax, and what technology criticisms does that eliminate?

The biggest criticism of digital fax is that it’s not structured. By structured, I mean that you are mapping specific data fields from one system to the next. Fax comes in as an unstructured document, such as a PDF, Word document, or chart. It’s not broken down into its discrete fields. 

When that document is received, whether it’s a two-page prior authorization or a 500-page patient chart, it’s just a big PDF. What am I going to do with that big, unstructured document? If you stop just with the digital transmission, even through a cloud-based digital fax protocol, that’s the knock on fax. It doesn’t get me to where I need to be. I still need to scan through the document or read it to figure out what it entails.

With the introduction of large language models, which is the generative AI that is permeating all parts of society, I see the ability to grab unstructured data, pieces of information, from a 500-page patient chart through a large language model that can understand the context as well, which large language models are really good at. They extract the key pieces of information that are needed for the recipient. That will transform how digital fax will have higher quality, lower cost, and better efficiencies for healthcare than try to use things that have been around for a long time. I get to be too geeky, but it’s called CCDAs to structure all these fields in HL7 and FHIR to map all these discrete fields from one system to the other.

Why don’t we just do this mapping and do all this structured data exchange? Again, you just have to look at the volume. Epic has anywhere from 50,000 to 150,000 discrete data elements, based on the configuration, and every configuration of Epic alone is different. Doing that mapping isn’t rocket science, but it takes a lot of one-time work and ongoing effort to keep that up versus just sending the whole document through a secure, ubiquitous protocol that everybody has. You don’t need FHIR, HL7, a QHIN, or HIE. You have a phone number, so you can leverage the telecommunication backbone and security that is already there. Now let technology do the work to bring that unstructured document to life.

That’s relatively new even for our company, and within the overall digital fax industry. But it’s a way to transform interoperability within healthcare.

How much of the information in those documents needs to be integrated into the EHR and other systems?

The unstructured document that comes into the hospital, usually through digital fax protocol, is still probably at least 80% of the transmissions in healthcare. We’re seeing Direct Secure Messaging, and think of that as secure email. Maybe it’s about 10% of the transmissions right now. When you do it through a Direct Secure Message, it comes in through structured, but the challenge is that it doesn’t represent all of the data.

You can’t put an image in there, obviously. You’re not going to structure clinical notes. You still have to provide some unstructured data, which gives context to the recipient, the physician who needs to review the patient who was just imaged at a facility or gone to an emergency room, to get the whole context of the patient.

You call your AI approach “Practical AI.” What does that mean?

We call it Practical AI because it’s exactly what it is. A lot of AI doesn’t add much value. Ours is practical because it’s pretty straightforward and we’re focused on solving real, practical problems. So with 10,000 documents coming into a payer, hospital, or pharmacy, is it a purchase order that goes to finance? Is it a prior authorization with high priority that needs to be responded to within the next 30 minutes because there’s a patient in an ER waiting for that prior authorization? Or is it a claim that needs to be processed in the next 30 days? The first part of our Practical AI is that we’re going to look at this document that just came in and identify its type. 

The other part of the practical side is that in healthcare, nine times out of 10, there’s a patient associated with it, and probably a provider and a record number. We have to extract the patient and identify them by date of birth and address so we can find that patient in the recipient system. That’s a practical use of AI to classify, extract, and then decide what the system needs out of this 50-page document. Sometimes 20 pages and sometimes only three fields. We will make it practical in terms of what’s needed for this incoming transmission for that hospital provider or payer.

How does AI fit into the hype cycle and your company’s business strategy?

It is definitely advancing along the hype cycle and finding some real practical uses. We who use ChatGPT or any of the tools see its ability to digest information in human speech, synthesize information, and create really nice clinical summaries. If the meeting you’re in has three action items, you don’t have to take notes, because it’s going to find it for you. That’s the practical side of how AI is being used.

In our world, we’ve been doing machine learning for over 10 years. It requires a lot of training and use. It gets more challenging and specific with the introduction of large language models. Now you can throw large pieces of information at a large language model, especially when it’s been fine tuned with customized prompts for healthcare, to add real advantages of efficiency, accuracy, and clinical efficacy in the delivery of care.

HIStalk Interviews Peter Bonis, MD, Chief Medical Officer, Wolters Kluwer Health

Peter Bonis, MD is chief medical officer of Wolters Kluwer Health and an adjunct professor of medicine at Tufts University School of Medicine.

Tell me about yourself and the company.

I’m a gastroenterologist. I was at Yale on my first faculty job when I was recruited to join UpToDate as a startup. I joined the company, and along with many other capable people, I was able to lead it to grow, scale, and become a very important information resource that is used by healthcare professionals around the world.

Wolters Kluwer acquired UpToDate in 2008. We became part of a portfolio of information services across different verticals. Those verticals include health, tax and accounting, finance and corporate compliance, legal and regulatory, and corporate performance and ESG.

What are the advantages of presenting clinician-authored or clinician-supervised content at the point of care rather than using the literature search engine approach of some of your competitors?

Let’s frame the issue. Patients expect their doctors to give them the best possible advice. It’s a covenant that doctors would be seeking to counsel their patients with the best possible information.

As it turns out, clinicians have regular questions. When they get answers to those questions, they in fact change decisions about 30% of the time. As readers are out there doing the thought experiment of being with their clinician, imagine that they would change their plan if they had a particular piece of information. Those are the stakes.

We decided to address that information need, which has been well documented, by recruiting a faculty of the best people in the world who are clinically active and who are contributing to the body of knowledge in the area that they are writing about.

We framed the approach by understanding the types of questions at an extremely granular level, having an evidentiary way to look at the body of evidence, make that transparent, rate the level as a recommendation so that it’s highly transparent, and infuse into that the wisdom of these people who are some of the most deeply experienced clinicians in the world.

Human curation not only can summarize the body of evidence, but also can add to that the clinical wisdom and experience of considering factors that are important, such as patients’ values and preferences, to issue recommendations that are granular enough to be used at, or near, the point of care.

Doing that purely as a matter of information retrieval, even with advanced technology, is complicated. The expectation is that that technology can ingest all of that material, present it, prioritize it, and consider all of those factors that I just mentioned to make that experience transparent for both clinicians, and ultimately the patients that they’re serving.

Clinical decision support in its early days pushed guidance indiscriminately on physicians, with the assumption that they should digest it all and also to avoid malpractice issues from not offering complete advice. How do AI-focused tools address that, and could AI itself tailor the content to what an individual physician sees and how they react to the information, such as measuring overrides?

That is the frontier and the challenge, and indeed it’s the opportunity. We have plenty of opportunities to inject knowledge at or near the point of care, both for matters that might be more operationally focused, but also in this high-stakes domain of clinical care. Doing that well can improve care, remove friction, and help to ensure that every patient gets the best possible care, no matter who they are seeing and where they are being seen.

Doing that well is extremely challenging. It requires an enormous commitment to be sure that the experience is as accurate and usable as possible. And where feasible, to include information that is relevant to specific patients and make that experience transparent enough so that the clinician who is ultimately making those decisions can feel confident in the accuracy of that decision, or at least to be sure that they can serve as an interpreter when applying it to the patient in front of them.

To do this well, particularly in this area of decision support, requires a enormous commitment. You have to be sure that all of the different components of that which can break down are done as well as they possibly can be, and to provide an experience to clinicians that is as transparent and as effective as possible.

The business model of massively funded OpenEvidence appears to be running drug company ads that are targeted to the retrieved medical information of the patient. Will clinicians see the ad-supported model as a conflict of interest?

We focus on what we do and have always done well. We have been entirely supported through subscriptions. We have extremely strict policies related to conflicts of interest, particularly among our internal staff, but also all of our 7,500 external contributors, the external faculty and peer reviewers who contribute to UpToDate. We have found that important for maintaining integrity, increasing transparency, reducing bias, and ensuring that our sole purpose is to deliver care recommendations that are clear, unbiased, and free of any commercial taint.

Whether that can be done with a different business model remains to be determined. Ultimately, the market will let us know where the cracks are in that type of a model.

We will continue to do what we do and do well, which is to have a commitment to deliver an effective and easy-to-use experience, focusing on making it easy to do the right thing wherever frontline healthcare professionals are working in their EHR in an enterprise environment or on their mobile devices, Making that experience as free from bias as possible to ensure safety to the best of our capabilities. Providing transparency so that the entire experience is grounded in information that has been curated by humans, and in fact some of the most experienced clinicians in the world.

Will standards of care change as enterprise-associated physicians are provided access to sophisticated knowledge tools while others are financially forced to do without or to use free resources such as ChatGPT?

That’s an excellent point. It really comes down to the matter of how widely governance can be established across healthcare enterprises and small institutions as well. Obviously the governance involved in advanced technology such as AI requires a multidisciplinary approach. It’s not clear that that is going to be available widely for all of the different types of institutions that could take advantage of these technologies.

I do think there is a potential for creating a digital divide, or at least to have some institutions which have governance processes in place and others which may be relying on third parties such as their electronic medical record systems to do that governance process for them.

It ultimately comes down to the safety and effectiveness of the information services, particularly in the high-stakes domain of clinical decision support. For an institution that employs doctors, it’s not just the doctors, but it’s the institution itself that has risk involved, along with the potential benefits of helping to achieve high quality, consistent, and safe care. Having the right information available is certainly a fundamental piece of that equation.

Everybody cites the supposed fact that it takes 17 years to incorporate research findings into frontline care. Will that go away as point-of-care tools can put fresh information right on the screen of the person who is making a clinical decision?

It’s interesting you mention that. The 17-year statement has been cited often, to the point where I decided to hunt down one day the original source of that. In fact, there is documentation, but it’s much more nuanced than that. And in fact, it is not 17 years.

A lot of the adoption of new technologies and new approaches is related not just to having the information available, but also other factors, such as financial incentives, convenience, and superiority over alternatives. But there is a process of information diffusion. 

UpToDate since its origins has done very well to accelerate that process. We have, for many years, showcased some of the newer concepts in a specific feature within UpToDate called Practice Changing Updates. It describes what is new to ensure that our subscribers have an efficient way to know when practice has changed because of new studies, new guidelines, or simply new knowledge that has accrued.

Now with more tools available at or near the point of care, including Gen AI, that process will continue. Ideally, as new technologies evolve and new knowledge evolves, we as a system will have an easier time at implementing them for the right patients.

The physician who is making decisions from the EHR may be presented with patient summaries or suggestions, information they already know but might miss, and new information that they are seeing for the first time. How do you present that without overloading them data they don’t need?

It’s an excellent point. Doctors are overloaded, and that fact is critical to consider. 

Studies have looked at the number of tasks that clinicians have to perform to fulfill all of the requirements that are expected of them. Primary care, for example, would have to have about 26.7 hours per day to complete all the tasks that are required. That is impossible to achieve, obviously, so there’s always a matter of triage. Designing systems that do not produce a cognitive overload is a critical part of the overall design process, and also the approaches of who should be doing what. It doesn’t always have to be clinician facing.

The potential for overloading clinicians is absolutely there. Many organizations are seeking to have that mindshare and to inject knowledge in front of clinicians, and all of it can’t be done. It has to be prioritized and it has to be effective. How that will look is still a work in progress. There are many efforts to do this using advanced technologies, but there’s also a long track record of what works and what doesn’t work.

I’m optimistic that we can do better and that these advanced technologies will have an important role, but the devil is in the details. How will this work within workflow systems? What will the interaction look like with the data that are available within the clinical record, and perhaps even from other sources, to create an experience that helps frontline providers and their patients? That will be the journey that we’re on.

If I can digress for a moment, what is happening to the patients in all of this? All of what we are talking about is taking place in the background, when there is an enormous erosion of trust in healthcare services and healthcare professionals taking place in the backdrop. Patients are increasingly fed up. They are looking for alternatives. The healthcare system is increasingly unaffordable, and it delivers variable quality of care depending on where you are, your level of insurance, and other factors as well.

In more recent surveys this year, 15% of consumers don’t trust their doctors, which is up from 7% in 2023. Only 24% believe that their healthcare systems are focused on caring for patients, down from 77% in 2020. Instead, about three-quarters believe their hospitals are mostly focused on making money.

This process of busyness and the business of medicine is having a fundamental effect, not only on clinician burnout and the actual care delivery, but in a very fundamental way around trust and the experience that patients are having. Ideally, technology will help this problem, both for frontline providers and for patients who are seeking to have a better, more affordable experience.

We are in that potentially awkward phase where some physicians aren’t interested in technology for technology’s sake, but digital natives are coming out of medical school who can’t wait to do everything electronically. How will that change the way that physicians are educated and then trained?

There has already been an organic adoption of technologies, particularly by younger clinicians and those who are trainees. That has been going on for a very long time. It’s really no different that an adoption cycle occurring with Gen AI as well. Although it’s not uniform, clinicians of all ages and career statuses are facile at adopting technologies for it.

But I do think it will change education in many ways and we’re on that journey as well. One is where AI fits into traditional education and the awarding of continuing medical education credits. Is an AI experience and AI-generated content sufficient and trustworthy, for example, to award continuing education or CME credits?

For students, can you adapt these technologies to support a more effective learning journey and a lifelong learning journey? Certainly AI has been applied for adaptive learning. We at Wolters Kluwer have had a lot of experience in this area, and there are opportunities there.

There’s also training around healthcare professionals being an effective consumer of information services. And particularly now, to understand the limitations of Gen AI and how its convincing and compelling answers can make us falsely believe that they are accurate when they clearly need more interrogation.

A final point is that there is an emerging literature about the degradation of learning from overreliance on Gen AI tools. There is some empirical data that reliance on Gen AI tools might lead to a decreased ability to retain and then to apply that knowledge in other settings. That’s a fundamental pedagogical change. Where this comes out and how educators will approach all this remains to be determined.

For the moment, clinicians at all levels, including trainees, are adopting Gen AI tools. It’s important that the tools that they are adopting to lead to their training and to patient care will be effective, safe, and reliable over an extended period of time.

What about AI governance?

Governance is important. It is tempting to use tools that are expedient. In fact, they are so compelling that there’s a tradeoff that I think clinicians are willing to take around expediency when they haven’t really taken a sharp look at what’s being traded off for accuracy, reliability, and some of the other dimensions of challenges related to the core technology.

The word that I’d like to get out is the emphasis on adequate governance. That can be by a third party, such as the electronic medical record vendor who is forwarding and embedding these tools, or the governance committees themselves at institutions. They need to be sure that all the tools that they are onboarding that are provider-facing, or that take advantage of advanced technologies, are properly vetted, scrutinized against important benchmarks, and transparent. If there are deficiencies, you  have the tools necessary to understand those deficiencies over time in domains like we operate such as decision support, where a right and wrong answer to an untrained eye or even to a trained eye can look equally good.

You need a gold standard to be sure that each answer is complete, accurate, and contemporary. That’s hard to do, but nonetheless, that’s the work that needs to be done to be sure that we’re helping all the healthcare professionals live up to their covenant and deliver the best possible care for their patients.

How do you choose a company strategy when AI and other technologies change literally every day?

Across Wolters Kluwer, we have a lot of experience with adopting advanced technologies. Across our verticals, we have already released more than 20 Gen AI related products and services. We are reinvesting constantly into advanced technologies and innovation, including AI, SaaS, blockchain, and other emerging technologies.

In the area of clinical decision support, such as what UpToDate provides, we have to really live up to our own standards in this high-stakes domain. There’s an evolving regulatory framework, but we understand our North Star. We understand in constructing this content that we are part of a medical community. We adhere to those standards. We have 55 physicians who work for UpToDate as deputy editors. Many of them are still in practice, mainly in academic medical centers. So the culture is one of patient safety, of seriousness, of understanding that there is a live patient somewhere behind all of our computer screens.

We have taken our time, as we have looked at the advances and particularly in Gen AI and how they can be applied, so that we adhere to our own standards and the standards that have been expected for our more than 3 million users out there. That means very, very careful product development and extensive testing. We’ve had a lot of innovation around ways to ensure reliability, accuracy, and validity, including not having the known pitfalls of Gen AI solutions like the degradation of context.

These things are very important. Generic Gen AI tools, for example, may recommend drugs that can be unsafe because they don’t ask contextual questions such as, is the patient pregnant? We have found examples of generic Gen AI tools that recommend drugs that are potentially perfectly suitable for the condition, but not if the patient is pregnant or they could be harmful to the fetus.

There have been many examples like that, so we have to understand the limitations of the technology and understand where the technology is going. We grounded it in this database that we have built over 30 years, which is not only summarizing the evidence, but infusing it with the clinical wisdom of deep experts drawn from a faculty around the world.

It’s our own commitment, our own standards, that are deferential to what is expected of us from our customers and the responsibility to take our time to test, release slowly, develop feedback mechanisms, and ground exclusively in UpToDate not the chaos of the internet, and in my view, create one of the most effective Gen AI solutions for decision support that currently exists.

HIStalk Interviews Dan Dodson, CEO, Fortified Health Security

Dan Dodson, MBA is CEO of Fortified Health Security.

Tell me about yourself and the company.

I have been in cybersecurity since about 2014, and in healthcare IT for 20 years. Fortified Health Security is a cybersecurity company that is focused exclusively on healthcare. We provide two kinds of services, advisory services and our managed security service provider business, or MSSP, for 24×7 monitoring and management of cyber technologies.

How does a healthcare-focused cybersecurity firm work differently than a more generalized company?

The attacks, adversaries, and the vectors they use are similar to other industries. The difference is how you respond to those threats and adversaries and risk reduction.

We believe strongly in having a knowledge base and an understanding of how healthcare organizations work, not only from a governance and regulatory perspective, but regarding infrastructure, legacy applications, mixed environments, EHRs, and medical devices. We build our playbooks and recommendations to take those elements into consideration. Our clients get more actionable intelligence so their teams can respond and take actions faster with the intelligence that is infused into our recommendations.

The top things organizations are trying to work through are AI, third-party risk, and training and awareness. Those three things are what organizations are talking mostly about with us.

What findings have surprised you in performing security risk assessments?

One surprise that we see is that everybody is at a different spot, and the weaknesses and the opportunities to improve are pretty vast. We’ve seen a lot of organizations make investments in different areas, some of which are reducing the risks that they set out to do. Sometimes they have opportunities for improvement. But as they’ve built their program over years, some areas tend to have significant gaps.

Third-party risk is a big area where organizations are struggling to tackle those challenges. Obviously with the rise of AI, we are in the early innings of understanding that from a risk perspective at the client side.

A lot of conversations are happening around end-user training and development. It’s a big challenge to actually drive better utilization of the tools to combat phishing, et cetera.

Are easily guessed or shared passwords still a big problem?

That certainly is still a challenge. The vast majority of compromises that could lead to a breach of data involve the end-user clicking on an email and giving up their credentials into a phishing email. Then the adversary comes in, moves laterally across the environment, and ultimately causes havoc. That’s still the number one entry point, so organizations are focused on combating that.

It seems like tools should have gotten sophisticated enough to block the clicking of suspicious links.

Tools are out there, and not having a tool would certainly increase your exposure. But this is an area where the adversaries are good. They are able to navigate around those tools and ultimately end in the inbox.

We see organizations thinking about how to reduce that attack surface. Do I have employees within the healthcare organization that maybe don’t need external email to execute their job? That’s a little bit of a culture challenge, because in the US, people associate their employment with having email. No one really talks about that. It’s the norm.

We are seeing some creative designs around that to make sure that we are limiting the attack surface. There are actually some cost benefits as well, such as fewer licenses for whichever email that you may use.

The other approach is training end users. A recent development is that most people are familiar with someone who was compromised personally for some type of phishing attack. Or, they have been impacted by breaches at Target or Nordstrom’s. One part of training is whether to focus more on the personal side and helping users understand how to protect themselves at the individual level. That would ultimately increase the level of protection for the organization.

What about users logging into their company email from personal devices?

That is still an issue. BYOD is prevalent. We have a lot of contract labor. If you live in a metro area, physicians have multiple privileges at multiple facilities. 

Who is winning the AI war between hackers and organizations?

I think the data would would tell us that the adversaries are being more successful. Breaches are continuing to occur. If you look at the Office for Civil Rights, the number of breaches year over year is stabilizing, but the impacts are getting larger. So I would say that, unfortunately, the adversaries are probably winning that fight. The adversaries are also using AI to launch more sophisticated attacks, both via email and help desk voice impersonations. They are definitely leveraging AI to hit us on all fronts.

How is the government’s role in healthcare cybersecurity changing?

Our view is that we are in a little bit of a standstill. There was a lot of energy at the end of the Biden administration. Senator Warner was leading that charge. Frameworks were put in place for programs that would provide clear expectations, along with some monetary support in a carrot-and-stick model to adopt said frameworks.

But a lot of that has stalled. The current view is that we may see tweaks to frameworks and expectations, but monetary support coming alongside that is probably off the table, at least in the near term.

Hackers have threatened to report their breach to HHS or have contacted individual health system executives, board members, media outlets, and even patients to threaten to expose breach information in hopes of getting a ransom payment. How do you address that dynamic, especially knowing that you wouldn’t be paying the most of honorable people with no recourse if they don’t deliver?

That’s the biggest challenge if you have a ransomware event or active breach that ends up in some type of negotiation. Thinking about adversarial intent, bad actors come after us to begin with because it’s monetary. They will pull all the strings that they can to create as much leverage against that organization to increase the likelihood of payment.

Also driving that behavior is class action lawsuits. Attorneys who used to chase car wrecks and malpractice cases have turned their eyes to cyberattack class action lawsuits. The adversaries know that, so they will weaponize that against the victim that is under attack. They will pull the strings on anything they can do to increase the likelihood of payment.

What are the advantages of organizations moving from point tools that are monitored by understaffed internal security groups to moving to a more centralized approach?

In most healthcare delivery organizations, teams are quite small. A lot of those individuals have been at that healthcare organization for a number of years and have made their way to the cybersecurity team. Health systems in general are not the best at training and having dollars available to train resources.

How do we make those individuals who have institutional knowledge about the networks, environment, and culture of the organization as effective as cyber warriors as possible?  We partner with those organizations to bring high-fidelity, actionable information to that team so that they can take quick and swift action.

As far as which service or what opportunity, I would just tell you that every healthcare organization is at a different point in their cybersecurity journey. They have made prior investments. Can our organization plug in, leverage existing investments, and operationalize that in a more efficient way to ultimately drive down risk?

One of your reports about downtime preparation quoted a chief nursing officer whose hospital experience an unanticipated problem because young nurses couldn’t read the cursive handwriting that doctors used to write paper orders. Is it common to find problems during downtime that weren’t anticipated in the plan?

Almost every time. Organizations do their best to prepare for downtimes that are short in duration. Hospitals go on diversion a lot for various reasons that have nothing to do with cybersecurity. They have downtime when they have to patch a system, implement a system, or upgrade a machine. We are relatively good at doing that for a short period of time. The challenge arises when you are down for a long duration and you don’t really know how to manage through days or weeks of not having access to the systems.

That’s driven by a couple of things. One, we are heavily reliant on systems when delivering care, whether that’s the EHR or the hundreds of other applications that power these health systems. So when they are down to some degree, the clinicians are frozen in their normal work habits. Anxiety and nervousness sets in because they want to take care of the patients, but they don’t have the technical controls in place to ensure that they provide swift, quality care. It slows down the care delivery model significantly.

Calculating is another issue we see. How am I calculating if I’m making an order for a particular medication? Med reconciliation is another thing that drives a lot of nervousness, making sure that I’m giving the right meds at the right dose to the right patient. Most of that at scale is done electronically, and that becomes an issue.

Communication is also another big challenge that we see. How are we communicating as a team if we’re using some type of a pager system or a walkie-talkie-system like Vocera and it’s down? That’s how we are used to communicating.

Lastly, a lot of the younger physicians have never operated in a world where they haven’t had technology. They were trained on an EHR at med school and they’ve been delivering care for years while being guided by electronic systems.

How do you advise organizations to deploy resources to protect their ever-increasing reliance on external technology vendors?

Step one is understanding how you interact with those third parties technically, so that if they have an event, you can take quick action to sever ties to limit the disruption to your organization from an adversarial perspective. But then comes the challenge that you need that system to deliver it, but the reality is that for the hundreds of systems that are that are in these healthcare delivery organizations, there’s not enough dollars to have backup systems for every single one of them. It’s unrealistic, both monetarily and operationally. That would also double your attack surface, so it’s not necessarily recommended. The first step is getting your arms around all of your third parties.

Step two is determining what the interaction is between your organization and those third parties. 

Step three is putting in some contractual language and some compensating controls on your side to try to limit the downtime.

Step four is that as you think about the disaster recovery plan, work with your clinical teams to understand how they would operate with certain critical systems down. Start with the ones that are most useful clinically and are most widespread so that you have some type of backup plan in place in the unlikely event that it’s unavailable.

What is the company’s strategy over the next few years?

Our strategy is to continue to work with healthcare organizations to increase their cybersecurity posture. We believe very strongly that a coordinated, programmatic approach through various elements of their cyber program can help minimize that risk. We are going to invest in our central command platform, which is our service delivery platform that provides actionable information and drives results across their entire organization to reduce risk.

HIStalk Interviews David Bates, CEO, Linus Health

David Bates, PhD is co-founder and CEO of Linus Health.

Tell me about yourself and the company.

I’m a scientist, engineer, and entrepreneur. I spent 16 years in venture capital. I’ve also started a few companies along the way. I’m passionate about brain health, its importance in the world, and how much suffering can be alleviated by preventative, proactive care, equipping people with agency over their brain health.

That speaks to the introduction of Linus Health. We have a brain health enablement and dementia prevention platform that spans the care continuum. It is clinically integrated, but it’s not just in the clinic. We want to care for people all the way through their life journey to optimize their brain health and prevent disability.

How does the diagnostic process differentiate between occasional forgetfulness versus true cognitive impairment?

The approach we take is unique, novel, and well validated. We mimic what specialists have done for decades by analyzing the process by which a person carries out a task. We leverage multiple sensors in a tablet, smartphone, or laptop to analyze the characteristics of their behavior. 

Behavior is the primary observable output of the brain. We deconstruct that behavior to understand any kind of emergent brain dysfunction. There are many kinds of brain dysfunction, not just a catch-all memory. There is executive function, language, visuo spatial, and of course memory. For each of those, it’s important to understand the type of impairment and what is likely giving rise.

The treatment, the intervention, can then be specific to work on that particular aspect of brain function, and as much as possible, improve health, improve function in their daily life, and equip them with the tools and capabilities to compensate for whatever disability is emerging.

That’s really important. It’s not just a binary thing, impaired or not impaired. We need to understand what is actually going on with this individual and how we can help them optimize their daily life and promote health in their brain.

What is the trigger for performing the test? Is it a one-time diagnosis event, or does regular screening have value?

I’m a big believer in preventative health. We should not wait for disease. We should be proactive in our brain health. It’s important to have a baseline. Everyone should be their own metric of how they’re doing, especially when it comes to brain health, so you can catch things early.

I believe in doing a brain health screen wherever healthcare is delivered. Wherever you would check blood pressure, you should check brain health. It’s important because with these new tools, you can catch things years before they would show up as symptoms. When you catch it early like that, you can intervene early.

It’s akin to oncology. You don’t want to wait until you have a tumor bulging out of your neck or they’re all over your body. You want to find, as early as possible, any kind of emergent illness and then intervene during that window of intervention to preserve function and health. With the brain, it’s incredibly important, because neurons that are lost are not recoverable.

To your point of should we screen? Absolutely. We need to change the way that we think about brain health. We need to understand that there is something that can be done. There is incredible hope for people. Many of them don’t have to get dementia. Up to 45% or more of cases can be prevented through lifestyle modification. Treatments are coming to market and getting approved by the FDA, so the earlier the right people can get started on them, the better the prognosis.

I’ve talked to people with Alzheimer’s disease who are living, in their words, their best life. They have known they’ve had it for a number of years. They are on one of these disease-modifying therapies and are still living their life, traveling, doing things with their kids.

Alzheimer’s disease is not dementia. It can result in dementia, but it can also be slowed down. Not every person with Alzheimer’s disease will get dementia. It’s important that we have this education and understanding in the market so there’s not a fatalistic view.

People are proactive in assessing their brain health and proactive in doing the lifestyle modifications. Those who need it will seek treatment to preserve brain function. With dementia, every single person can benefit from brain health assessment, especially with good platforms, even if they have dementia. Equipping care partners with knowledge and resources, equipping the individual. It’s a dyad, the two together that the patient and the care partner know how to optimize health and quality of life. Not only the life of the afflicted person, the patient, but the life of the care partner. If they’re not equipped, informed, and supported, their health suffers tremendously in the majority of cases.

That’s on the dementia side. Back to Alzheimer’s, detecting it early, even so-called pre-symptomatic. Platforms like Linus Health can find them before symptoms are apparent. Intervening and preserving function is incredibly important. People can live a much higher quality life than if there’s not intervention.

Intervention is not just “take this medication.” It’s holistic, and they need to be engaged in many ways, including for some the disease-modifying therapies. For everyone, it’s a discussion among themselves, their doctor and the family, and figuring out what is the best treatment course for this individual. It stands and it is irrefutable that the sooner you engage, the better the outcomes, and the better the quality of life for the individual and for the family.

Can that diagnosis and management be scaled by using non-specialist clinicians instead of less-available specialists?

With the right tooling, primary care can handle the majority of cases. They’re rightly positioned to. It is similar to how they now manage diabetes when it used to be an endocrinologist. Managing hypertension used to be a cardiologist. Those specialties are still needed and are used on the more difficult cases as their training warrants.

It’s using the right resources for the right people. The majority can be managed in primary care. Platforms like ours provide those primary care physicians with the capabilities to diagnose and the decision support to triage, to guide them to care for those individuals right there in the primary care setting. Especially addressing their modifiable risks, addressing reversible causes. That can all be done in primary care.

For cases that need specialist care, they should be referred right away. This helps streamline referrals, reduce wait times, and get people to the right resource as expeditiously as possible. That optimizes healthcare.

What is the role of biomarkers, which are in essence a blood test for dementia? How does that fit with cognitive testing and could they be applied to a population?

The approval of Fujirebio’s blood test, Lumipulse, back in May was a huge step forward in Alzheimer’s care. You need to first establish a cognitive impairment. Some of the key opinion leaders in the field have shown that with these blood biomarkers, they need the establishment of some kind of functional impairment to make their predictive accuracy appropriate and meaningful.

It’s a great addition to what I would call the emerging service line for brain healthcare, especially cognitive care. The blood biomarker helps, once you’ve established that there’s a concern with memory or thinking, what is the likely etiology? What is causing that impairment? If the p-tau blood biomarker is positive, it is very likely that the individual has Alzheimer’s disease. They should be triaged, if appropriate, to disease-modifying therapy or one of the many drugs and intervention methods that are coming out that can deal with that etiology. 

It’s equally important to know that it’s not Alzheimer’s disease, because you want to work on other contributed factors to find out what is giving rise. That could be a co-morbid condition like unmanaged hypertension, unmanaged diabetes, undiagnosed sleep apnea, and the many other things it could be. Get those things treated and then retest. For those who are appropriate, getting them to a neurospecialist since it could be Parkinson’s, Lewy bodies, or a variety of things.

That blood biomarker is incredibly important to know how to triage people following a cognitive assessment.

How do payers approach cognitive conditions?

Unfortunately, we’re seeing a number of payers that are not, in my opinion, assigning appropriate value to brain health. I don’t know if it’s broadly appreciated yet how important the brain is and how important it is to the quality of life and health of the individual. The brain is that organ that you can’t transplant. It’s important to who we are. I don’t know if the health system and the willingness of payers fully reflects the value of brain health and function. 

Members should demand more brain health focused resources to preserve their quality of life. Dementia is the number one health fear of middle-aged and older people, yet it’s not standard to assess cognition to try to prevent dementia. CMS does reimburse. There are CPT codes for the digital cognitive assessment. There are CPT codes for brain health visits. There’s a reimbursable pathway. 

With value-based care, CMS has done a great job, especially Medicare Advantage. They have risk adjustment factors. They have certain HEDIS exclusions. They have the incentives aligned with identifying and caring for cognitive issues and dementia care.

That’s at the CMS level. Different insurers take different stances on cognitive assessment. Maybe they don’t want to pay for the expensive disease-modifying therapies, so they don’t want to screen.They don’t see that the patient will be a member that long. Some of them don’t take an active role to support brain health care, and that’s really a shame. We need to do better than that.

You could say, “That’s because you have a company that is associated with finding emergent illness with the brain.” No, it’s because I’m a human being. I care a lot about brain health and I hate to see people suffering from it. If your primary goal is to insure people for health, you need to make sure that the things that are most important to their health are being looked after. If you do the right thing, everyone will win. It will pay off in the long run. The total cost of care will go down. People’s quality of life will go up, and there will be a lot less suffering.

Have studies looked at the age of onset and the insurer at the time of initial diagnosis? I’m wondering how much of that happens before people reach Medicare age.

The studies are emerging. It’s early days. There is the empirical evidence, which we need more of and I’m sure is underway. We are tracking people and we want to make sure that we have those cases.

There is precedent in all other chronic conditions that early intervention, early management, leads to reduce total cost of care. The best thing that we could do, and we need our system aligned, is to incentivize prevention. But our system is aligned to treat sickness, and so all of the incentives are around treating sickness. This is a policy matter, but how do we incentivize prevention? How do we enable people to take action over their brain health and reduce significantly the disease burden?

Neurological disorders are the number one disease burden in the world. Neurology in psychiatry is still an emerging area, especially with new tools and capabilities. But there’s a real opportunity here. Most health stems from the brain, and every other function is to support the brain. It’s good to start on first principles. How do we optimize brain health, and from that comes total health.

To your point on the insurers, I do appreciate that they have a business to run, and you can’t paint with broad brushes. Some of insurers are proactive in promoting brain health, even some of the largest ones. Some have taken a stance, while others have decided to put their head in the sand. That has never been a good strategy. You’re saving some dollars on the front end, but you’re causing irreparable harm to so many families.

How has last year’s acquisition of Together Senior Health changed your capabilities?

It has given us another step forward to enabling people to have a higher quality of life, even those who are living with disease, and their care partner. We’ve taken the RADAR tool (Risk of Alzheimer’s and Dementia Algorithm) to a validated capability that is now in production. We can risk stratify entire populations for the risk of undiagnosed disease. That enables insurers and health systems to know who is likely to be suffering from illness, the presence of emerging illness, and the risk of it. That’s where we should focus our care resources to minimize disease impact as much as possible.

You take it all the way through our platform and through the clinic. Then, back at home, how do we care for those individuals and optimize their brain health trajectory? The acquisition of Together Senior Health was a big step on those bookends, risk stratification on the front end and the engagement and care on the back end. That has helped complete our platform to span the continuum of care, all the way from identification, diagnosis, treatment planning, post-clinic engagement, and health coaching and monitoring.

How do you expect the company’s business to change over the next few years?

We are seeing the engagement of health systems across the country. They are leaning in increasingly. So I expect to see in the next two years that the standard of care will be set, and the service line will emerge for cognitive care. It will be such a good thing for the world, for the population. I see it spreading into Europe, the UK, throughout North America, Asia, and beyond. Get to Africa, get everywhere, and promote brain health.

We need to work on the stigma that is associated with dementia. We should not have a stigma. People should realize that it is a new day. There is incredible hope. The drugs that exist today on the market, and especially the ones that are coming, are tremendous. They are showing such benefit, and it’s still early. Everyone needs to know that there’s tremendous hope for the future.

We need to treasure the senior population. They are pillars of the community. They have so much life experience. We need to honor them by caring for their brain health and getting them the attention and resources that are needed to prevent dementia. That is super important.

HIStalk Interviews Kevin Healy, CEO, ReferWell

Kevin Healy is CEO of ReferWell.

Tell me about yourself and the company.

I started in the CEO position at ReferWell in April of this year. Before that, I worked with a private equity group called Chicago Pacific Founders, where I was an operating partner and CEO for one of the portfolio companies that I helped build and get moving. Prior to that, I was with Optum for 12 years, where I led the sales and growth teams in Optum Insight at one point, Optum Health at one point, and Optum Rx at one point. I had the pleasure of sitting within all three pillars of Optum. Before that, I had several startups, build-ups that led to successful exits.

It has been a whirlwind of healthcare over the last 25 years. Before that, I was in the golf business, so it was an transformation, obviously, from golf to healthcare [laughs]. It has been a wonderful experience.

I love this business. I love ReferWell. What attracted me to ReferWell and pulled me out of retirement was the product itself, which was incredible. But just as important were the people in the company. The team was amazing, dedicated, smart, young, ambitious, and ready to go conquer the world and fix the healthcare system. I loved the energy and the product itself.

ReferWell is a simple company. We do one thing, and we do one thing very, very well. That is, we get people to the doctor. Companies, health plans, and hospitals spend thousands if not millions of dollars to find out who they need to outreach to. Then they spend lots of money to find out what happened to those patients after the outreach. But very little, if any, is spent on actually getting them to the doctor.

I liken us to a light bulb. The light bulb is big and bright, but without the filament in between, it doesn’t work very well. ReferWell is the filament that connects the two entities. Who do we have to reach out to and engage, and what has happened with those individuals? The big part is about what happens to them when they get to the doctor. We do that better than anybody else.

What are the patient barriers to making and keeping appointments and following through on referrals?

It’s an overwhelming issue. Close to 40% of all appointments go missed. Sometimes when an individual is at the doctor, the doctor says, “Mrs. Jones, you need to go to see a cardiologist” and hands her a list of cardiologists to call. Or you have to go see multiple doctors, so you get a list of multiple doctors to call. Sometimes they happen, but 40% of the time, they don’t happen. That’s a barrier of understanding who to call, not being able to reach them, not being able to find an appointment, or not having transportation to get there. Also, not really understanding why they need to go.

Part of our unique positioning in the marketplace is not only about technology, but about people. We believe that people, our care navigators, are an integral part of this process. It’s not just using an AI or an AI agent. We have real people talking to real people about real problems and real issues. That’s extremely important. We can never take that human touch out of health care, and we never want to. But we can support it with advanced technology.

Our proprietary scheduling platform allows us to schedule with our care navigators, or for a provider or a payer to schedule, at the time of communication, or at the touch point with the patient or the member of the health plan to be able to set an appointment at the time of engagement. It sounds so simple, and the amazing part is that it is a simple idea that is hard to execute. That’s where ReferWell comes in.

How can patients be helped to choose a specialist from that list that their doctor has provided?

The unique factor is that the federal government has been kind enough to rate health plans, and health plans have been kind enough to rate physicians and practices for quality of service and quality of outcome. It’s kind of a cost-quality equation that health plans, for example, apply to doctors. They a four- or five-star rating, just like health plans have a five-star rating. 

It allows us to filter based upon location, so the closest to the office of the physician that they’re visiting or closest to their home or their place of work. Then also by quality. The highest-quality cardiologist within a mile from my house, or two miles from my house, and these are the doctors that have available appointments in the next week or two weeks. Quality and location filtering has to be taken into account.

We have multiple sources of information that we absorb, so we can triangulate that information into who would be the best for this individual to go to. It gives them options.

We’re not making the clinical decisions. We’re letting the patient, the doctor’s office, or the health plan help them with those clinical decisions. We’re just offering up the information and telling them what’s available in terms of spots, schedule appointments, etc.

Provider directories have always been a challenge to maintain, so the patient calls down the list and finds doctors whose practice information and insurance acceptance isn’t current. Can that be automated, or does it always end up with someone making a phone call?

The answer is not as simple as one might think, but the progress has been significant. The feds have been all over provider data management, the information that is available to members of health plans of all types, Medicare Advantage, Medicaid, commercial, ACA lives, etc. Several organizations are out there that maintain correct information, and we contract with three of them.

We then have to decide which of the information is most accurate, and sometimes our team needs to make an outreach to find out which is correct if we have conflicting information. But that’s our job. That’s what we offer. Then we update the systems so that everybody has the correct information.

Provider data management has come a long way. It’s not perfect, but on the health plan side, there are fines for not having your provider data management up to date. We use some of the same companies that they use to inform our decision-making process.

It’s impossible, really. Doctors work in several offices, different times of day, different days of the week, different days of the month, across multiple communities, and all of that changes. It’s hard to have it 100% correct, but technology is helping more with that. The groups that we partner with are very, very good at keeping up their data, and that helps inform our decision-making as well.

Aligned incentives would occur if providers benefitted from keeping their schedules full, but if they are employed, they may not see the value of being busier, or maybe their schedule’s already full so they don’t really care. How do practices view the idea of having the schedule availability their providers visible outside?

We look at it in a way that may be a bit hopeful, but I think that most physicians want to give great service to the people that they can provide service to. There is a sense of control with having their own schedules and opening it up seems like a little bit of a loss of control. But they also know that they have the opportunity to serve and work with more individuals. It always behooves them to keep their schedules full, even on the employed side, because they are incentivized to do so and they intuitively want to.

Getting access to schedules for providers has been a difficult process. One of the reasons is that we have so many different electronic health records out there. We have to integrate with them so that we can see what’s open and what schedules are available.

It’s difficult to get doctors to agree to allow people to see their schedules. But as more and more groups start to look at accountable care organizations and are going at risk for the care, care management, and the health and wellbeing of their patients, they are incentivized through financial rewards if they provide good service and have great quality outcomes. They are raising their star levels and want to get that word out there that they are a high-quality care center and can be counted on to have access and will provide quality care. 

It is an opportunity and a change of a mindset for providers as much as anything else, a little bit of relinquishing control. But for example, UnitedHealthcare has a gold card program that stack ranks people by quality of outcomes, and with that comes rewards. As part of that, I can imagine a day when they have ReferWell as their scheduler, and tell providers that we have to have access to your schedules to get the gold card program, either complete access or partial access via a ReferWell platform. Other health plans have the same type of program as well.

Our North Star at ReferWell, that Holy Grail for us, is having organizations recognize that engaging the providers and rewarding the providers for good behavior and good outcomes means that they will have a great partner. It changes the healthcare structure from fragmented to more of a synthesized, hospitality-like structure.

That’s where we’ve lost faith in our healthcare system. It’s fragmented. They don’t talk to each other. All of a sudden we can start talking to each other. Providers, payers, and hospitals are all talking to each other via scheduling mechanism.

It seems like a benign way to do this, but it’s amazing what it would mean in terms of how easy it would be to synthesize all three entities into a much more cohesive care management journey for an individual who has just left the hospital. How do I make my next appointment? Who do I make my next appointment with? Does my health plan know that I have my next appointment with them? That’s the dynamic that has to change. 

Is it more common that the clinician who makes the referral knows that the visit actually happened, or wants to know, or what its result was?

It is becoming more common for them to want to know. But it’s also more common that the patient understands that their primary care physician knows that they had an appointment at another facility or doctor, and maybe even what the outcome was of that particular appointment. It has always seemed odd to me that if something would happen to me and I end up in the hospital, my primary care physician, who has been looking over me for many, many years, has no idea that I’m in the hospital, because I’m not able to talk to them. Connectivity is needed that has not existed in the past. 

That becomes a comforting factor for a patient to understand that their doctor knows that these things have happened. They know what meds I’m on, no matter what doctor I go to. They know what services I’ve had. It makes it feel like the whole system is talking with each other. They can schedule the appointments and have the data from that appointment in their electronic medical record. They can talk to me about what transpired and how I feel since then. Or get in a better understanding about my overall health and wellbeing.

The patient is going to drive this. The patient is going to want their providers to have this information, and they will have a better overall experience when they do. Imagine if you called Marriott’s hotel reservation line to ask if they have a hotel in New York City. They say, “Yes we do, thanks for calling” and they hang up. Wait a minute, I’d like to make a reservation. That’s how healthcare is. You need to make the appointment and get scheduled. It has been barrier after barrier to do so. It’s a less cohesive an experience when they don’t have the information at the provider level. That just needs to end.

We aren’t saying that we are curing all the issues with healthcare, only that an integral part that has never existed is this connection point of getting people to the doctor, finding out what happened while they were there, and then providing the referring doctor with the information about what took place at the visit. It doesn’t seem like that big of a deal, but it is a meaningful and impactful overall consumer experience that is going to change.

How do you expect your business to be affected by changes in federal policy or in federal payment policies?

The government is doing a very good job in several areas. I know that’s not a popular statement to make. But when it comes to healthcare, the government is trying to drive hospitals and doctors towards this accountable care model. The accountable care model is all about payments, all about follow the money. But what they’re trying to do is follow the money, but also follow the outcomes. For us, that changes the dynamic of what’s required. The federal government is forcing our healthcare system to go in that direction. It has been tried and tried and tried. For provider practices with the ACO model, hospitals are getting in with the CMS TEAM model — Transforming Episode Accountability Model — under five different categories of care. 

It’s hard to say that the government has a heart sometimes [laughs], but they have a heart, it’s in the right place, and their heads are in the right place. We just have to put it in action, and I think we’re on the right path.

My six months at ReferWell has not disappointed. It’s such a wonderful little organization and been around for 10 years. It is finding its feet right now and I’m excited to be part of it.

HIStalk Interviews Steve Cagle, Board Advisor, Clearwater

Steve Cagle, MBA was CEO of Clearwater at the time of this interview. He transitioned to board advisor on September 30.

Tell me about yourself and the company.

Clearwater is a healthcare-focused solutions firm that provides cybersecurity compliance and managed security services to hospitals, health systems, physician practice management groups, digital health, and health IT companies. Really all types of organizations in the healthcare ecosystem. We help those organizations to be more secure, be more compliant, and be more resilient so that they can achieve their missions.

I’ve been CEO of Clearwater since May 2018. My background is in healthcare. I started my career in a software company that provided quality management software to help pharmaceutical companies comply with FDA regulations, such as good manufacturing practices. I then spent some time in the pharma industry in consumer healthcare products, running a business before returning back to technology and compliance here at Clearwater.

How do health systems decide how much effort and money to invest in cybersecurity?

Unfortunately in healthcare, most organizations have been historically underinvested in cybersecurity. However, we have seen over the last five years or so an increased focus, especially following the pandemic, when we saw a wave of ransomware attacks on healthcare organizations. Then we had the Change Healthcare incident a year and a half ago, which affected about 70% of the providers and caused very extensive damage.

As healthcare organizations have continued to adopt new technology, technology has become critical to operating their businesses or providing care to patients. They have realized that cybersecurity mission critical and requires them to have the appropriate protections in place to reduce risks.

That’s really the key word. It’s about understanding your organization’s risks beyond the high level. A lot of organizations have done high-level risk assessments. They may be helpful as a starting point. But we need to go much deeper in today’s environment, where attack techniques have evolved to become difficult to defend and protect against.

Organizations have had significant impacts from ransomware attacks and breaches. That’s why the Office for Civil Rights of HHS, which enforces HIPAA regulations, has been focused on risk analysis and their risk analysis initiative. Risk analysis in healthcare requires that organizations understand where they have electronic protected health information, where they have those critical systems that support their operations or are connected to those systems with EPHI, and that they evaluate the vulnerabilities and threats, assess the controls that are in place, and determine the level of risk that exists with each system.

By doing that, organizations will be better informed as to where those high risks are. Based on their risk threshold, they can then identify those risks that fall above that threshold and put specific risk remediation or risk management plans in place to address those risks.

That’s a business-focused way of approaching cybersecurity. It’s not checking boxes. It’s not trying to have the best security program in the world. It’s really understanding your risk at a level that is appropriate. Then, taking actions to bring those risks to an acceptable level.

What were the most important lessons learned from the Change Healthcare incident?

Risk analysis. Clearly there’s been a lot of uptick in organizations really understanding, “I need to get to that next level. I’ve been doing the same type of assessment for many years. I’m going to invest more money into doing that risk analysis so that I can have better information about my security program.“

We’re seeing a lot of attention on cybersecurity and risk from the board of directors and the executive teams. From a cultural perspective, there has been a change in healthcare where this has become a priority that organizations need to focus on.

We’ve seen big changes in resiliency, where organizations have plans in place to not only respond to a security incident, but also to contain it to operate under duress through a business continuity plan. Having updated disaster recovery plans and testing those to make sure that they are effective.

As we look at all the solutions out there that are based on artificial intelligence, we have new concerns. There was a big rush to implement a lot of these new technologies that are based on AI. Unfortunately, many organizations did not take the time to establish policies and procedures about how they will use them and to assess the risks around these technologies. 

It is still risk analysis, but it’s a different set of risks and different set of controls. We are seeing a lot of interest from our clients in helping them to establish governance around artificial intelligence, cybersecurity, and privacy, or to assess their risks of those programs and to help make sure that they are implementing these technologies in a responsible way.

The mainstream press loves headlines about the devastating impact to patients of a local provider that has gone down from a cyberattack. How much do we not hear about providers who are successful in preventing that kind of attack?

That’s a very important point that you’re making. We hear about the bad news, but we don’t hear about the good things that are happening.

We’ve done over 650 NIST Cybersecurity Framework assessments for our clients over the last 10 years. We track and trend maturity levels over time. We see that the industry is becoming more mature. We track over time the organizations that adopt the NIST Cybersecurity Framework, which is a commonly accepted and used framework in healthcare, and we see that they are improving above the bar of the rest of the industry. There’s really good data that we can point to that demonstrates that we are making progress.

The challenge is that the bar keeps getting higher. You have more vulnerabilities, more threat actors. Threat actors have been very successful in obtaining ransomware payments from healthcare. They pay more often than any other industry. When it’s easier to attack a certain sector that is more willing to pay and pay more, that’s going to attract more threat actors.

You don’t hear about organizations that are being responsible. They are assessing risks, maturing their security programs, and not having those attacks. Or if they do have a security incident, they are able to address it quickly and with minimal impact. They have network segmentation and other types of controls in place that make it difficult for threat actors to exfiltrate the data or to do damage.

We will continue to see that maturity improve over time. But we have to realize that unless we stop developing and implementing new technologies and increasing the attack surface, it’s not going to stand still. The bar is always going to become higher.

How often do providers pay a ransom, and if they do, what is a typical outcome?

Fewer providers are paying than in the past. A few years ago, it was 67% of the time, and that number has gone down probably closer to 50%.

You really can’t trust criminals. A lot of them will try to uphold their end of the bargain because they want people to continue paying, but that’s not always the case.

There’s also double extortion. You get the encryption keys to unlock your systems. Maybe some of these organizations have good backups in place and are willing to take the downtime that it takes to restore those systems, which could take days or weeks, or longer. In some cases, those encryption keys do not work. They’ve done so much damage that it doesn’t really help them.

Then the second extortion is to get the data back. Often the data will end up somewhere else in the future. Paying the ransom doesn’t give you any guarantees. You’re really taking your chances. That’s why you are seeing fewer organizations making that payment.

How do organizations allocate their spending across prevention, detection, and rapid recovery?

We always recommend starting with a baseline set of controls and adopting industry standard best practices. We can point to the NIST Cybersecurity Framework. We can also point to the 405(d) health industry cybersecurity practices. Those are both recognized security practices in healthcare based on an amendment to the HITECH Act in January 2021.

The 405(d) HICP is a great place to start because it is provided in different volumes for small, medium, and large organizations. It was developed through collaboration with over 600 firms in healthcare — providers, vendors, and the government. It’s a practical way of setting up those baseline controls. 

Once you’ve picked a framework and standard, you go back to how much more you need beyond that. That comes down to the other requirements that you have. Do you have compliance requirements that you need to meet? Maybe even ones outside of HIPAA. Do you have clients, partners, or payers that require you to meet certain security standards, maybe a SOC 2 audit or HITRUST certification? What’s your risk profile? What kind of risk as an organization are you willing to accept?

Then you do that risk analysis to see where you have gaps between your current level of risk and what’s acceptable. Using all that information, we create a target profile. It’s a long-term roadmap of where we want to focus. That will help determine where to make those additional investments. We know the minimum requirements for standards and practices, but going beyond that, what is the organization’s specific situation? 

What is the value of health systems communicating regularly with their boards about cybersecurity, and what metrics are most useful for board members to understand the situation?

We speak to a lot more boards now than we did maybe five years ago. It’s pretty frequent. One of the key functions of a board is risk management. If the board is being informed of the other types of risks across the organization, cybersecurity has become an important area of risk, and one that they need to be informed about.

Typical things that we will talk to boards about are trends, particularly across the sector, and the higher-level concerns or risks that they need to think about.  

The board should be putting the governance in place. What higher-level policies do we want to have as an organization? What is the level of risk we are willing to accept?

Sometimes, but not as much any more, we see risk tolerance levels being set by more at the operating level, the IT department. The IT department is not the risk owner. If a security incident renders a hospital in a position where it can’t see patients, that’s a board level issue. That’s all the way up to the board. So the board needs to decide how much risk we are willing to take. How many resources are we willing to apply? And then put the management team to work with the mandate and the support to implement a program that will ensure that the organization is in line with those policies and is on a path to meet that risk threshold.

We have to keep in mind that risk changes over time. Just because we are below our risk threshold today doesn’t mean that tomorrow we’re not. We do M&A, acquire a new part of the business, partner with somebody else that includes new third-party risk, changing the threat landscape. It’s constantly changing, so the board needs to make sure that that risk management program is prioritized and resourced. Then getting information to know that it’s actually being executed appropriately.

What changes do you expect to see in HHS OCR’s enforcement of HIPAA and security?

The Office for Civil Rights has been focused a lot this year on its risk analysis initiative, where it’s making sure that organizations are prioritizing that risk analysis that I spoke about earlier. The notice of proposed rulemaking was released at the beginning of the year. Part of that rule contains updates to the risk analysis requirement that reflect its current enforcement actions and guidance.

A lot of other requirements are more specific and are required under the rule. I don’t think that rule in its current form will necessarily be the one that is eventually published. I do think, however, there will be an update to the rule or at least some additional standards that organizations will need to meet. The HIPAA security rule was last updated in 2013. The world has changed a lot since that time.

Most of the industry is looking for something specific we can point to, not overwhelming, but addressable. Ideally with some support and help from the government, especially for those smaller organizations or rural health organizations that don’t have the resources or the money to improve the programs the way that they would like.

What does the company’s strategy look like over the next 3-4 years?

Our strategy is to be a market leader in healthcare cybersecurity and compliance. To do that, we need to have a full set of capabilities that are relevant to healthcare organizations. Not just today, but over the next several years. Our strategy is to continue to ensure that we can provide those services to our clients in a way that helps them reduce costs, become more efficient, and focus more on their mission, whether it’s treating patients or driving their business. Being a partner and extension of the organization to help them address cybersecurity compliance.

We are excited about our growth at Clearwater. We are grateful to have dedicated professionals in the organization, as well as a growing list of clients that we collaborate closely with. We are dedicated to this industry and looking forward to continuing to serve this industry and help make a difference in healthcare.

We are thrilled to announce a growth investment from Sunstone Partners, which is a private equity firm that focuses on tech-enabled services with a particular focus in cybersecurity and healthcare. That makes them a great partner for Clearwater going forward. We are excited to have a great partner that can help us better serve our clients. We will be investing in more technology, as well as continuing to scale the organization.

HIStalk Interviews Michael Raymer, CEO, Vitalchat

Michael Raymer is CEO of Vitalchat.

Tell me about yourself and the company.

First, I just want to thank you for saving a lot of lives during COVID. Your post about Co-Vents, the not-for-profit that I set up to get refurbished ventilators into the field early in the pandemic, allowed us to connect with the Stryker family, which funded our efforts. We estimate that we saved 20,000 lives, and that all started at HIStalk.

I think you call me the timeless veteran of healthcare. I’ve been involved in large companies driving big innovations, such as GE Healthcare and Microsoft. I spent the early days of my career working on ventilators at Nellcor Puritan Bennett. Since I closed the days of Microsoft, I’ve been focused more on earlier-stage companies. I sold my last business, Pro-ficiency, to a publicly-traded company last summer and joined Vitalchat in October of last year.

Vitalchat is a flexible, AI-driven audio and video platform that enables nurses to practice virtually, and supports procedural telehealth. I joined because video is probably the most underutilized signal in healthcare. We have all sorts of data, more data than we can use. But when you combine video with data, it can enhance the care delivery process.

I’ll also mention that I write a weekly blog post on LinkedIn for those who would like to follow my thoughts about healthcare, strategy, business, and people.

How does a health system use ambient, AI-driven monitoring to enhance nursing capacity?

We have automated nearly 70 workflows. Our implementation teams identify the workflows that are the easiest to implement with the greatest ROI, which may vary by health system. Common uses could be the safety check where you match the IV bag to the patient, which typically involves two nurses being in the room. When you use virtual technology, you can have the nurse at the bedside complemented by the virtual nurse remotely, who is able to zoom in on the IV bag and also the patient ID band to make sure right patient, right medication, right time. That’s just one of 70 workflows that we support with health systems today. 

One of our key accounts is University Hospitals in Cleveland. Their first 150-bed pilot cost them $1 million to implement and they generated a $10 million savings over the first year. Now they’re on the pathway to roll it out across the entire healthcare system. Every day they are encountering a new potential use case for the product. That’s what’s so exciting about bringing in under-penetrated technology and to see all the possibilities for improving care for patients. That’s what it’s all about.

Can the technology bring nurses back into the workforce who left due to physical or geographic limitations or frustrations with floor nursing?

Absolutely. We see that the most successful virtual nurse is one who came from the floor and knows some of the other caregivers on that floor.  But most importantly, they’ve seen almost everything that could happen in the care of patients. They are a steadying hand supporting the nurse on the floor. 

We have heard many stories in our customer base about nurses who likely would have retired or pursued a different career, but took advantage of virtual nursing to continue to provide their unique skill set to health systems. That’s very gratifying. We have a projected shortage of almost a million nurses by the year 2030. If this can help stem the outflow of nurses outside of the hospital, that’s a great thing. We are seeing lower turnover rates and higher nurse satisfaction with having our virtual platform in place.

Do hospitals usually rotate floor staff, or are the virtual nurses people who don’t work regularly in the facility?

I don’t want to generalize, but these are not roles that are being filled by traveling nurses. They are clinicians who have worked in the healthcare system and are well trusted. Some of our sites have a rotation, where they may be three weeks in the virtual care operations center and another week on the floor. That keeps the connection with the clinician on the floor and allows them to understand how they could even be more effective in the virtual command center. That’s a good model for those who are physically able to go back to the floor.

It seems that skilled nursing facilities would be a good use case, although they have limited financial and technological capabilities.

I spent time in my career in the skilled nursing space, which is certainly economically challenged. A variety of use cases can be positive, including medication administration. You typically don’t have an onsite pharmacist, so the ability to have a remote pharmacist interacting with the patient and the physician onsite. You have issues of patients who are worried about falls, such as a movement in the room that might indicate that the patient is trying to get out of bed when they have been deemed a fall risk.

There is significant opportunity in skilled nursing. The issue is the price point. Because we’re agnostic to the hardware platform, we believe there will be an opening for us ultimately in the skilled nursing space, but we’ll probably follow that through the channel of our customers as hospitals. In fact, this week we had a great discussion with one of our customers going out into the home with that subsidiary. We can scale the hardware appropriate to the particular situation, so it could be a great fit.

The Big, Beautiful Bill will allow more money to be funneled into the rural healthcare system, where 25%-plus of the patients in this country are taken care of. The bill allocated $50 billion to technology like Vitalchat provides. Being able to allow that patient to remain in that remote facility supported by a specialist in the tertiary care academic centers was brilliant in the bill. The patient wins. The remote facility wins, because they’re able to keep that patient. The patient’s family wins, because they aren’t having to travel long distances in support of a loved one.

At the same time, the healthcare system can get reimbursed for the specialist care without them physically having to be on site. If necessary, the patient can be transitioned to that academic medical center. Fully implemented, the vision of that is particularly powerful, and you can extend that analogy to skilled nursing.

Is your technology’s footprint light enough to avoid a rip-and-replace of existing technical and physical infrastructure?

One of the technology constraints is bandwidth consumption. We have patents in video compression that allow us to be a very quiet signal on the hospital network. We move the AI to the edge and do not use cloud resources to process that video. Response time is outstanding. We wind up not being traffic on the network that’s going up to the cloud to implement AI or ambient learning from that video signal. Reusing hardware that’s already in the facility.

We recently created a solution for customers of ProConnections, a tele-ICU vendor that closed late last year and left their installed base abandoned. Because our platform is flexible and hardware agnostic, we created a solution where we provide software on their existing hardware platform so their customers can continue to use that product in monitoring patients.

What opportunities does AI offer in analyzing video without requiring human eyes?

The future of care is ambient. You see a lot of announcements in the ambient speech space. It will be more and more assistive over time. We were talking with one of our customers today about a dietary use case. Looking at the plate that’s delivered versus what it looks like when returned, then being able to assist nursing with caloric calculations and the I&O workflow sheets that nurses manually fill out today.

There is such tremendous opportunity to look at workflow as the technology improves. The AI engine, in our case, is easily trainable. I can’t even conceive of all the use cases. Today the dietary one came up and I never even thought of that as a potential use case in the acute care setting. It’s a big time-consumer for nursing. It would give them more time to spend on patient care and not documentation.

Today, it’s 70 use cases. A year from now, it will be double that number that will be proven to add value.

Are the companies working in this area of video analysis specific to healthcare? Also, how do you sort through those many use cases and decide which ones to go after first?

The platform that we built is easily trainable. In fact, we began using NLP as a test case for allowing a clinician to build the kinds of things they want to observe in the room. Our ambient AI engine will process requests by the clinician and provide them immediate feedback.  There’s not a lot of software work that we have to do to enable new workflows. 

A health system has super complex workflows. If you are shifting something from an in-room activity to virtual-based, everyone on the care team needs to understand that. There has to be the appropriate accountability, both for the nurse in the room and the centralized command center.

Most of those workflow challenges are not software issues for us. They are workflow challenges for the health system that are not unlike originally implementing the modern EHR. A tremendous amount of workflow design was done. The beauty of our product is we don’t have to build flowsheets. We don’t have to build order sets. We are insulated from the inherent complexity of an EHR.

We don’t see a lot of big companies in the video space. We see companies much like Vitalchat. A lot of people saw the headlines last year in Stryker’s acquisition of Care.ai and the vision of merging the device company with visual insights. We believe that being Switzerland is a better strategy, not being tied to just one vendor. It allows us to work with Epic, Oracle Cerner and devices in the patient room and in the OR.

The space is interesting. It is not just the AI ambient technology, but also the wrapper around it. The complexity of running video and audio from a patient room is non-trivial. We have been able to bulletproof our platform. I call it a self-healing technology, where our uptime is up from three nines to four nines now for our in-room cameras. If you’re going to rely upon this technology 7×24, it has to have that amazing reliability. That may have been the most difficult challenge technologically, getting the uptime to be there that is necessary to deploy at scale.

We started out talking about COVID and Co-Vents, which brought back unpleasant memories of patients dying in locked-down hospitals with families having their last moments with their loved ones via an IPad. Can technology like yours improve the experience of patients and families and not just that of clinicians?

That is a very personal issue for my wife and me. We lost my mother-in-law during the dark days of COVID. They would not allow my wife to come in the hospital to see her. There was not any kind of technology that allowed us to even have an interaction with her. Fast forward to today, that has softened the landing of this technology in patient rooms, because patients understand video consults now. FaceTiming with family members and similar tools are mainstream. 

I heard a great story two weeks ago where one of our customers was able to have a patient in the hospital be a participant in a wedding. Not just viewing it, but actually having two-way audio communication with family members in the wedding while the patient was in the hospital. We hear story after story where our technology has allowed that patient to connect not just to caregivers in a health system, but also loved ones, and to have loved ones join consults at the bedside from remote across the US or across the world.

What are your plans for the company over the next two or three years?

My primary job as CEO is making sure that the rate we’re growing will allow us to have both the monetary and people capital that are required to support our customers. The good news is that I have a very big Rolodex. When we have a need inside the business, it’s easy for me to reach out to my network and plug individuals in immediately who can make a difference for our customers.

This is an exciting space. A strategist would call the inpatient virtual nursing setting a $2 billion total addressable market. You have less than 5% of the beds in the US that are penetrated with video and audio. That’s a significant opportunity for us to make a difference. It’s exciting to be early and exciting to have unique capabilities in our platform that will allow us to sustain impressive growth over time.