HIStalk Interviews Charlie Harp, CEO, Clinical Architecture

Charlie Harp is CEO of Clinical Architecture of Carmel, IN.

Tell me about yourself and the company.

I have been developing software in healthcare for a little over 30 years. I’ve worked for companies like SmithKline Beecham Clinical Labs, First Databank, Zynx Health, and Covance Central Labs. Back in 2007, I started Clinical Architecture to address what I thought was an unmet need in the healthcare industry, which was doing a good job of managing how information moves, how we deal with terminology, and how we deal with content. It’s designed to enhance the way we support patients in healthcare and look at information.

What are the challenges of using provider-generated data for operational improvement, benchmarking, analytics, and life sciences research?

There’s a handful of issues with the data that we collect in healthcare. If you talk about just standard structured data — and let’s even include unstructured data — one of the big challenges is that every single application in every single facility tends to be its own little silo of terminology. Code systems that are created in these places by the people who work in those places are usually local. They are not always following the best practices in terms of how they are described.

Public health organizations, large IDNs, or payers that go to collect all that information — even if it’s delivered in a standard container, like a CCDA or an HL7 transaction – experience semantic impedance. To be able to utilize all the disparate codes and put them into a common nomenclature or common normative terminology that you can do analytics and BI and all those things on, you’ve got to do work. You’ve got to introduce work to get the data from its original state into something you can use.

The other challenge we have is that if you look at the standards where we ask people to codify things with standard terminologies, not all mappings are created equal. You deal with that “whisper down the lane” effect with structured data, where they might have mapped it to a SNOMED code or an ICD-10 code for delivery through something like a CCDA or FHIR bundle, but there’s a certain amount of uncertainty baked into whether or not they broadened the term, they narrowed the term, or maybe somebody made a mistake and mapped to the wrong term. There is what I call uncalibrated uncertainty when it comes to the structured data.

The other problem we have is that between 60% and 83% of the data we know about a given patient from any place is bound up in unstructured notes. At the end of the day, what the provider relies on is their notes, not necessarily the structured data, because most of them realize that structured data has a lot of uncertainty in it.

What is the role of artificial intelligence in recognizing terminology problems faster and perhaps resolving them faster?

What we do is a form of deterministic artificial intelligence. We’ve trained our product over the last 10 years to understand certain clinical and administrative domains. When it gets a term like “malig neo of the LFT cornea,” our product parses that apart semantically and turns it into an expression — malignant neoplasm of the left cornea. We use that when we are doing things like mapping, so that we can do about 85% of the work.

If things are really terrible, and I’ve seen some really terrible things come through an interface, then obviously you have to pick up the phone. But in that scenario, what you’re dealing with is deterministic artificial intelligence, where a human being, a subject matter expert, has trained a piece of software to think like they do.

Machine learning is really pattern recognizers. They don’t set a course, they just observe something,. I always warn people that there’s a certain lemming effect of machine learning, where people could be doing a lot of wrong things and the machine learning doesn’t know right from wrong. It just knows patterns. When it comes to doing the transformation of data, the challenge is filling in the gaps of what’s not there. Most of the time when somebody’s struggling with mapping something, whether it’s a drug, lab, or condition, the core part of the struggle is there is something missing. There’s not enough information for them to determine where it should land in the target terminology.

Another challenge is that the terminologies that we use for standards are prescriptive. They are pre-coordinated. Somebody sits in a room, and they come up with a term like “Barton’s fracture of the left distal radius.” They say that, and that’s the term. Let’s say that you’re coming from ICD-10, you have Barton’s fracture of the left distal radius, and you’re mapping it to SNOMED. Let’s say that SNOMED doesn’t have laterality for Barton’s fracture. Most systems that we have today can’t handle post-coordination, where they can glue multiple things together and land it in the patient’s instance data. They have no choice but to choose a broader concept, so they choose Barton’s fracture and the other information left by the side of the road.

Even if we had the smartest artificial intelligence platform in the universe, you can’t map to something that doesn’t exist. The way we deal with structured data in terminologies today is that we use these single codes in our standards. If you can’t find an exact match, what do you do?

What are the risks of companies that assume that FHIR solves their interoperability problem only to find that terminology issues are creating incorrect or incomplete information?

FHIR is a great advancement, but it struggles with what a lot of standards struggle with — it’s a snapshot. We are evolving FHIR and we are using FHIR, but if you look at the old ASTM standard, HL7, FHIR, OMOP, or any of these canonical models, it’s good if we can have agreement that these are the elements we are going to share. When you ask me for a lab result, here’s a standard container that I can give to you. It’s less verbose in many ways than some of the things that we did in HL7, especially Version 3, but it does deliver things in a nice package. It’s good for us to have agreement in how we package things up.

The issue with terminology is a lot of these systems that we use in healthcare, in inpatient and in outpatient, have homespun terminologies. There is no way to get around doing this semantic interoperability. For a long time, we didn’t care, because we didn’t try to collect that data and use it in a longitudinal, analytical way.

FHIR is good. I wouldn’t get rid of FHIR. FHIR is a great advancement. It brings us to consensus on how we package things up, what things are important for a particular type of resource. The fact that people are excited about doing it and they are opening up some of these systems to share data in real-time ways that they never did before is pretty cool. But when I get a FHIR resource that describes a lab test, and it’s using the local lab code, problem ID, or drug code, it’s tough to map it to make sense of that data and do something good.

People coming from other industries say, why is it so hard in healthcare? A big part of it is the systems we built and the platforms we are in. That metaphor of fixing a 747 in flight is very true. You can’t go in and just rip the rug out from under a hospital system and expect that everything is going to be OK. It’s an incremental steppingstone of evolution to get where you need to go. People can suggest that we just get away from all these local terminologies, but that’s going to take a decade, easily. If we can get it done, it’s going to take a decade. We just need to have better solutions and better ways of dealing with this interoperability problem.

The other thing, when it comes to semantic interoperability, is that the onus is on the receiver. The people who are pushing data out have already used it. They are pushing it out to someone else because they have to, but they don’t have to suffer the consequences of it not being accurate or complete or not being coded perfectly. At that point, it’s out of their hands. The onus is always on the receiver of the data who wants to use it to make sure that it is usable.

I always request, when I’m doing some kind of a transaction, give me the original data, even if it’s not a standard. The original data is what the provider chose. It’s what the people said. I’m not going through some third party that picked the closest thing they could find in a list of standard terms. You can give me the standard term you think it is. That could help me a lot, because if they are right, I can use it just like that and I’m good to go. Having the original data eliminates some of that hearsay effect.

We have seen this with our product Symedical, where we have data, like say lab data. We saw a code of CA-125 come through Symedical and people mapped it mapped it to calcium. CA-125 is a cancer antigen test. It has nothing to do with calcium. Because Symedical looks at patterns, says, “CA-125 isn’t calcium. It’s a cancer antigen test.” We were able to fix that and put it in front of a human and say, “It came in as calcium, but this is what we think it is” and they were able to correct that. Those are the kinds of things we’re going to have to do.

A lot of people think that doing that mapping of data is a project, but in reality, that’s a lifestyle choice. It’s like mowing your lawn. You can’t just do it once and walk away. It requires somebody to be keeping an eye on that all the time, because the other thing that can happen is people can change a code. It doesn’t happen with the standards, typically, but it happens with proprietary code systems.

Our mission at Clinical Architecture is maximizing the effectiveness of healthcare. A lot of what we do when it comes to machine learning is not necessarily say, “This artificial intelligence will come in and replace what you do.” It’s really saying that this thing will do a lot of the heavy lifting. It will eliminate a majority of the work. But we never suggest that we can eliminate humans from the equation when we are talking about doing this semantic interpretation of what Human A created and what Human B created, because I create a code, it’s local, I have another person map it to a standard, and that standard comes into System B. The first thing that has to happen is the person in System B has to map it to their local code if they want to use it. 

That’s just point-to-point exchange. If I’m pulling data into an aggregation environment and trying to do some kind of analytics on it, it’s probably easier, because if I’m smart, I’ve probably chosen a standard and maybe extended that standard a little bit to accommodate the outliers. But it’s just one of those things where when we start utilizing longitudinal data from multiple sources, having mechanisms in place to look for things that are uncertain and allow me to rule them in and rule them out is going to be a pretty big deal. Also, looking at unstructured data for high-value information that I can use to improve that picture.

The other thing is using things like inferencing logic, where I can take the things that I know about the medical world and look for data that can’t be true and call it into question. I’m not a clinical person, so bear with me, but if I have a  patient who says they are a cardiac hypertroph and they have a procedure that says they have an ejection fraction of 25%, that can’t be true. There are situations it just can’t be true. If I have a patient who is on insulin and has a hemoglobin A1C of 7%, but there’s no mention in their structured medical data that they are diabetic, it might be in the note, but it might not be in the structured data.

We are trying to do things as we enter into this value-based, population health, analytics world. Look at the public health emergency we just dealt with in 2020. Being able to leverage that data in a meaningful, competent way is going to be critical as we continue to move healthcare forward.

Do you have concerns about drug companies aggregating de-identified EHR data from hundreds or thousands of hospitals and then making significant clinical or commercial decisions based on what they see?

Whether it’s the CDC looking at COVID or pharma looking at a particular situation or looking for cohorts to enter into a clinical trial, the first step is getting the structured data, taking whatever the original people entered into the system, and doing a good job of finding the best possible target. 

The other challenge you have is that because mapping is difficult, people don’t want to do it. Or they say, I’m only going to map the top 50, or I’m going to only map these three things I care about. You can’t really think about it that way, because the things that you are not mapping are a mystery to you. You have to try to map everything, even if you only care about 10 things. Mapping everything makes sure that those 10 things aren’t missing, because they could be if you don’t map everything. If you map everything, then at least you’ve got a picture of the data. 

If you have what originally came from the site, then you eliminate that third party that may have mapped it to a standard incorrectly. It’s good to have that data because it gives you hints at what they thought, but having the original data lets you analyze what the original thing said. Take my earlier example where you have Barton’s fracture of the left distal radius. I convert it to SNOMED, it’s Barton’s fracture and I’m going to land that in my data repository as Barton’s fracture. If I have the original term, let’s say terminology on my side has laterality and anatomic location, I can say, they said Barton’s fracture in SNOMED, but when I look at the semantic payload and the words that are in the original term, I’ve got the exact same thing in my database here as a term. It has a different code, but it says exactly the same thing. I can make sure that I’m not losing information in that transaction. Always try to get original data because you run the risk of terminological hearsay.

As a benefit of people who are aggregating data, as opposed to the old episodic way we dealt with healthcare, is that you get a probabilistic cloud of information about John Doe. When you get all that information, you could use machine learning or AI to help essentially reinforce things. It’s kind of like diagnosing a patient, I imagine. I’ve never done it, but you are looking at all this information and you are looking for things that corroborate or things that indicate that maybe this isn’t true. A lot of the time we just pull everything together and slam it into a list of problems and medications. We are still wrapping our heads around this whole notion of time in healthcare data. Healthcare comes from a very episodic place. We have never really sat down and looked at how should we look at longitudinal information when it comes to diseases, drugs, and labs, so that we can look for this flow of evidence that tells us what’s going on. When you start aggregating, it creates opportunities to do that.

We need to make sure that we are thinking about these problems of how we normalize information, how we look for information that’s missing, how we take information — not necessarily the big word salad output of NLP, but how we mine unstructured data — for things we really care about and make sure we’re integrating them into our information that we’re collecting for patients.

We didn’t have the idea of a data steward position in healthcare, but it will evolve as we enter the post-COVID era. We didn’t have a great handle on why and what was happening. The job of a data steward is to periodically have software that tells them “this data doesn’t look right,” so that we are constantly curating and improving the patient data, ideally involving the patient in that process, so we can have more confidence in that data.

I don’t know if people will say this out loud, but we don’t have a huge amount of confidence in our data,  in part because of all that uncertainty. Most people, whether they realize it deliberately or whether it’s just kind of this itch in the back of their brain, wonder if this data is good. Having a data steward function and having mechanisms that are constantly measuring and monitoring the quality of that data can dramatically improve our ability to have data that we can rely on to make better decisions.

Do you have any final thoughts?

This last year has shined a light on how important information is in what we do in healthcare. It’s not more important than taking care of patients, but we can create high-quality, actionable data as a by-product of taking care of patients. We can feed a cycle that allows the software to do a better job of helping providers, public health experts, and researchers be more effective and yield better results. I’m optimistic that we are on a trajectory to get to that place.

HIStalk Interviews Andrew Smith, President, Impact Advisors

Andrew “Andy” Smith is president and co-founder of Impact Advisors of Naperville, IL.

Tell me about yourself and the company.

I’ve been in the healthcare IT field for 30 years. I started Impact Advisors with my brother 14 years ago.

How are CIOs spending their time and energy as the pandemic seems to be winding down?

This is not a unique thought, of course, but what an interesting year it has been. Needs evolved over the course of the year. At the beginning of the pandemic, basically all work stopped and CIOs were redirected into pandemic response, supporting their caregivers. There was a brief respite in the August timeframe, where everybody thought that the wave was over and they could get focused back on business as usual. The second wave hit, everything shut back down, and now over the last two months or so, it appears that the world is starting to open up a little bit. CIOs are focusing back on their agenda.

What’s interesting, though, is that when I talk to our CIO clients, they all remark similarly that the one thing they appreciated about the pandemic was that the pace changed and the expectations changed. Things that they thought were going to take three years took three months or three weeks. The common thought they have now is, how do we keep that kind of execution and pace going? Because now they are all a year behind on much of their agenda. I’ve seen a real uptick, in terms of interest, pace, and the agenda they are hoping to accomplish over the next year.

Did work of the CIO and IT departments gain internal respect as they were freed of the shackles of multi-year, multi-stakeholder projects and just told to quickly bring up technologies such as telehealth and chatbots under crisis conditions?

Yes, exactly. The consensus-building, governance, and bureaucracy that held back a lot of these technology advancements went by the wayside, and it became streamlined. They needed to stand up a telemedicine program overnight, and for most of our clients, their telemedicine programs increased by a hundredfold. That didn’t require an executive steering committee and three sub-levels of subcommittees to get there, which is typically how we make those decisions, for all the right reasons.

Much of the technology work is really just the point of the spear of huge change management efforts, and big change management takes consensus, time, and evolution. We didn’t have that liberty or that luxury, so we had to move quickly. The real question is, how do we balance those two ends of the continuum with this need for speed with a need for cultural change and adoption? That is going to be the interesting thing to watch.

Will they pick up existing budgets and priorities given that the pandemic overlapped fiscal years and the associated budgeting process?

That’s a really great question. I’m not sure I know that the answer to it, because we are figuring this out. Capital and operating budgets have been upended and redirected.

Again, I hope that we can move at a different pace. Many of our clients have had to lock themselves down. I’ve heard our clients say, “When it’s budget time, I can’t afford to miss a meeting. Otherwise, it could cost me millions of dollars of budget.” You hope we get into a new rapid cycle of opportunity identification, benefits analysis, and then move into execution very quickly.

I fear that we may fall back to the bureaucratic ways of old and the staid pace. But I hope that one of the outcomes of this pandemic is that we get comfortable moving quicker and reacting quicker and understand that the industry is moving at a different pace, and that we need to react to it with supporting technologies and change management.

How will the demand for consulting services change over the next couple of years?

We feel blessed in that respect, because we have a broad set of service offerings, and that starts with our advisory and strategy. We are working with our clients to solve a lot of these problems, where many companies have to react to the market and the client demand. It feels like we are trying to help figure this out alongside our clients, which is nice because that means we can develop our service lines, methodology, and tools in lockstep and even in advance of where we see the demand in the industry. We have evolved the company quite a bit over the last year in reaction to this, and we’ll continue to do that.

Are consumer-facing technologies getting executive and budgetary attention?

Yes. Digital health is one of our most active service lines right now, as you would fully suspect, and that would include telemedicine. This is going to become a competitive advantage or disadvantage, and our clients are all worried about it. When the pandemic hit and they had to rapidly stand up telemedicine programs, they did that with bubblegum and duct tape and tried to figure out how to make that work. They were using FaceTime, Zoom, and all sorts of different technologies to cobble together a solution. They have all been circling back to say, “OK, how do I create a standardized foundation for this?”

The technology isn’t that interesting, quite honestly, but it’s all of the foundational elements, the process elements, and the care delivery elements that are so different. The challenge our clients are going to have is that if you try to layer digital health on your existing inpatient ambulatory infrastructure, that’s not going to be a real recipe for success. You need to think about this in a disruptive way of how to connect with the consumer in the community and how to interact with them in a way that’s convenient for them. You almost have to build a separate infrastructure. You need to think about this with an entrepreneurial mindset. But all our clients are worried about it.

Who drives that process in health systems?

A really interesting question, and I know you have some perspectives on this because I’ve seen you interview others around the concept of a chief digital officer or a chief patient experience officer. It is not a singular person, most commonly. It’s not typically the CIO, although the CIO is a major component and evangelist for some of these technologies. It could be the chief marketing officer, or one of those newer types of “chief” titles like chief experience officer, chief digital officer, or chief transformation officer. The real concern about that is that if you bifurcate that from the CIO and the technology, you’ve got an opportunity to layer complexity or miss an opportunity to streamline these things, to make it easier for the consumer and the caregivers.

Will people from outside healthcare be brought in since other industries are ahead of ours with consumerism?

Yes. We have seen that as a growing trend. The concern about that is that we have seen many waves of people from outside of healthcare coming in to rescue us. They don’t have a keen awareness or understanding of the complexities.

It’s a very odd industry we serve, where the consumer may be disintermediated from the bill they are paying or the cost of the services they are consuming. Although this is changing, in a lot of respects, the caregiver isn’t always completely controlled by the delivery system. It’s just a very strange industry that we serve. It doesn’t follow regular economic laws. I get concerned that people come in and think they can solve healthcare with a lot of outside industry experience.

But contrary to that is that we have been subject to a lot of groupthink inside healthcare, with fixed mindsets and the idea that we can’t do things differently because of the way it was in the past. Instead of standing up digital health, we’ll build a new building. That’s very dangerous thinking, too. The answer is somewhere in the middle. You need to infuse a lot of new thinking and also understand the restrictions or the models that work inside healthcare.

When you said “build a new building,” my first thought was that a progressive health system would sell an existing building and use the money move services to where consumers are. Along those lines, considering the rise of digital health and virtual hospitals, who will set the direction that defines exactly what a health system looks like?

The healthcare system of the future will continue the evolution we’re on, which is that health systems are looking to manage the breadth that they provide, give a closed ecosystem, so that they can care for their communities. They’re going to look to contract in broader ways for the health of the population. Now we’ve been saying that for decades, but we’re going to be right one of these days. That makes too much sense that we’re going to get into these Kaiser or Mayo-like health systems that are going to be resplendent across the entire nation. That just makes too much sense for it not to be true. There’s always going to be a need for a physical footprint for high-acuity people. But more and more of the care is going to move outpatient, more and more of the care is going to move to the home, and more and more of the care is going to move to a virtual environment.

What I fear is going to happen is that the haves and the have-nots are going to continue to become more disparate. That’s going to be a real problem, in terms of health equity, rural care, and the underserved. That’s trend that we need to be careful about, because the haves are willing to invest and gain some efficiencies, and the have-nots aren’t getting reimbursed at the level they need to continue to invest and evolve.

While we were all setting up vaccination sites and figuring out telehealth, federal rules took effect that covered price transparency, information blocking, and ADT notification. Are hospitals ready to address those?

They are aware of it. We did quite a number of advisory projects last year just to make sure that our clients are prepared for it, so I know it’s on their radar screen. I know they are reacting to it. My suspicion is they’ll be able to thread the needle, but your broader point is absolutely accurate. A lot of things have been changing.

There’s been a lot of scrutiny on information sharing and that trend is going to absolutely continue. We need to continue to move to pure interoperability and data sharing for the benefit of the consumer.That’s going to require a lot of change from the vendor landscape and from the health systems. I’ve talked to a lot of health systems and we, as an industry, still view that relationship between the health system and the patient as parochial. We view our knowledge of that patient, that consumer, as a differentiator. That thinking is probably going to have to break down over time and we will have to differentiate in other components, such as efficiency, cost, safety, and quality.

What level of interest are you seeing in robotic process automation?

There is this new uptake of RPA, which looks a lot to me like the screen scraping technologies that we used to talk about 10 years or so ago, Those certainly have their place and can be effective, but they are somewhat brittle technologies. If any of the underlying systems change, it’s a labor intensive process to identify and mirror your systems to it. The next evolution of RPA needs to be more dependent on AI and machine learning to fulfill the promise of robotic process automation, not just serve as a veneer on top of a screen scraping technology with its benefits and limitations.

Do you have any final thoughts?

In the last year, we’ve been through a black swan event. There was this period of rapid change, much of it negative. But we need to work hard to preserve the positive elements of it — the speed of change, the adoption of consumerism, and digital health. It’s an exciting time to be in our industry. We are starting to fulfill the promise of these big, monolithic EMRs. We have installed these and now can start to turn this data into information. 

I’m excited about what the next 10 years are going to bring. We have an opportunity to pivot the healthcare delivery system, and I’m excited that we will be along for the journey.

HIStalk Interviews Rob Culbert, CEO, Culbert Healthcare Solutions

Rob Culbert is founder and CEO of Culbert Healthcare Solutions of Woburn, MA.

Tell me about yourself and the company.

I started with IDX in the 1980s and worked with them for almost 10 years before switching over to the consulting side of the world. I started Culbert Healthcare Solutions in 2006, so it’s our 15th anniversary, although we didn’t get to celebrate it yet because of everything that’s going on in the world. We have been able to continue our passion for working with healthcare providers around the country, helping them improve the patient experience, improve financial performance, and solve strategic business problems.

How has the pandemic affected your business?

Initially, it was a shock, as was to everybody. It changed our business on a dime. For the first time in my consulting and work experience in 30-plus years, in April and May, we had zero invoices with expense reports on them. I never have experienced that in my life.We had a lot of things in place to be able to flip over to remote work. We had some projects pause, some ended, and some new ones kicked in, but we were able to make that transition as best we could.

We are a pretty conservative company and privately held, so we focused on making sure that we kept our people and took great care of the customers that we had and the new ones that had needs. We tried to be as creative as we could be to help them through their own crises. While I don’t think any of us are out of the woods yet until this thing really gets behind us, we have been able to weather the storm and continue the good work we try to do.

How are hospitals and health systems looking differently at their relationship with patients?

Pre-COVID, we dedicated a lot of effort to helping organizations improve patient access. There are lots of systems and functionalities out there. When you are doing a large-scale implementation like Epic, Cerner, or Allscripts, you don’t get to become an advanced user overnight. A big portion of our work has been helping to look at the patient access functionalities. It’s all about making sure that the physicians and the clinical staff have all the tools in place to be able to maximize utilization, to be able to have the right information to take good care of the patient before, during, and after the visit, and make that as seamless as possible. Some of that was for financial improvement. A lot of it was to prepare for changes and and the way payers pay providers for their work.

When COVID came, it was an easy process to flip to being as touchless as humanly possible. We had several engagements where there could have been pauses on the project, given all the uncertainty. But in the areas of patient access, customers said, keep going. The work that you have done so far has made those practices able to change on a dime. How do we deal with nobody in the waiting room? How do we remove all of the in-person touches that typically have happened? They were able to more easily adapt their schedules to follow best practice COVID protocols.

Are you seeing a lot of provider interest in buzzy technologies such as AI, robotic process automation, and life sciences research?

We are. Machine learning is, as with robotics and data analytics, a term everybody uses that means different things to different people. But everybody is dying to start using the data more effectively to make their jobs better. Especially during COVID, but we had started seeing it in the last few years. 

There’s a lot more for-profit investment firm interest in healthcare technologies. When a for-profit entity is looking to acquire a healthcare technology or provider, their approach to evaluating it, doing the due diligence, and then the speed of moving to realize the full value of that investment is different than what we historically have been used to in healthcare. It’s a welcome change, and in many cases, a needed change. It has been quite a transformation to see how more investor-led organizations are changing healthcare, much more that we saw in the first two-thirds of our healthcare career.

How will consolidation of both companies and health systems change the experience and outcomes of patients?

Unfortunately, the complexity of healthcare technology that we are trying to optimize is overwhelming for smaller organizations. It is more difficult and challenging for them to take full advantage of that technology, whether it’s from an expense standpoint or a skills perspective. There are definitely opportunities for larger organizations to be able to offer more complex technology with better support and more cost effectiveness. Economies of scale definitely make a difference.

There are different motives for some of the getting bigger. Some of it is to spread costs amongst the larger population. For others, it’s a business opportunity to be able to leverage that cost and provide a better service.

We have definitely seen cycles where there was lots of coming together, then there was lots of splitting apart. We’ve seen it come and go. This time, because of the complexity of the electronic data and the opportunities to streamline the healthcare process for the benefit of patients, it will be rocky in some cases, but the end game is going to be positive.

What is driving the sudden emergence of the chief digital officer title?

It’s a huge positive. When EHR implementation started, you had a lot of physician champions. The CIO was very much about managing risk and managing costs for those systems. It was much harder in the beginning to prove an ROI compared to the traditional revenue cycle system that makes your revenue cycle cheaper and more effective.

The concept of chief digital officer is different. It’s not just about managing the Epic system or the bread and butter system. It’s about managing the experience of the patients for the benefit of providers, so that they can have access to the information they need to do their job in a cost-effective and well-informed way.

Some of the vendors will hate me for saying this, but there is no one technology that does it all. We constantly see customers trying to take full advantage of the collection of technologies to be able to do as good a job as they can for the patient experience. That ranges all across the board. We have seen companies like CueSquared , which provides a mobile pay technology to allow patients to view and pay their statements on their phone. The world of self-pay has changed dramatically over the years, but that’s just one small example.

That digital experience has been interesting to watch, because a lot of organizations have created a serious digital approach to their world. Where does this fit into the patient experience we want? That’s where technologies get dropped and that’s where technologies get put in. Technologies that prioritize what’s important to the patient and help provide the patient great service, which might not have been given a look in the past because they aren’t a module within the larger system, are getting opportunities. They are doing some pretty cool things with it.

How will the cancellation of HIMSS20 and the delay in HIMSS21 affect the industry?

I don’t think it has had a negative impact on our company. I say that because the whole world has had to change on a dime. Everybody recognizes that as much as those in-person conferences can be invaluable for learning and networking, it just is impossible. But I’m still amazed by the amount of virtual opportunities that have, as best they can, replaced the in-person conference for now, the explosion of using Zoom, Teams, and GoToMeeting to be able to try to have some of that face-to-face.

One of our strengths as a company is that we have deep relationships with the industry and our customers. For those organizations that we know and they know us well, it was easier to go into a remote engagement opportunity. We were known quantities, there was a trust, and there was a relationship in which you knew that both sides were going to get good value. We were going to kill ourselves to make that remote process work, given historically that it was always an in-person or on-site type of opportunity.

For those that don’t know us and vice versa, it’s harder to build that trusting relationship. We have slowly started to see some of our engagements where there has been a strong desire to at least have some sort of on-site presence. Some of those have gone very smoothly. We have been creative, such as people staying over a two-week window as opposed to coming Monday and leaving for home Friday, to get through the window of time to build that relationship. And, to manage the COVID travel policies of the state that the consultant is going to and the state that they are coming from. That has probably been the toughest one for us, to make sure that we are managing those travel requirements between the two states.

We are starting to see many of our consultants getting the vaccine. We have had opportunities where they have qualified for the vaccine based on the work that is being asked of them. So far, that has made life a lot easier. Many of our consultants have no issue with traveling, because they have been doing it almost their entire careers. Others have been nervous about it, but we have been able to manage those nerves because we have been able to keep a fairly large percentage of our business on a remote basis. Each month that we are able to continue waiting for the world to be ready for the ongoing travel, then that concern will keep going down.

We are on the 10-yard line of hopefully the vaccine helping us to get to the other side of this thing. Just a little more patience is what we expect. Our people and clients have been flexible around managing that in a good way.

Do you have any final thoughts?

I am hopeful for everything that is going on with the vaccine and all the lessons learned to get us through this thing. Every customer and every business that we work with has had to adapt. We are at the top of that list as well. As hard as this year has been, it has been an exceptional learning experience. We are doing things that we probably never would have thought to do prior to COVID. In many cases, those things are incredible positives.

I am very positive in terms of the outlook. While this hurt everybody, we are going to benefit tremendously for years to come from some of the changes that were forced upon us. Creativity will stay with us in a good way for a very long time.

HIStalk Interviews Josh Schoeller, CEO, LexisNexis Healthcare

Josh Schoeller is CEO of LexisNexis Healthcare.

Tell me about yourself and the company.

I’ve been in the data and analytics space for over 25 years, the last 15 in healthcare. At LexisNexis Healthcare, we use data and analytics to help healthcare operate better and to create healthier communities. That’s front and center right now, given that we spend 18% of our GDP — over $11,000 on every man, woman, and child — for healthcare, yet we don’t even rank in the top 10. We have a lot of work to do, and our data and analytics can help us get better.

How are providers using third-party socioeconomic data of patients, either for care improvement or for their own business outcomes?

They are starting to use it more. I would say that we were pioneers in the SDOH space when we launched our product a little over three years ago, so we have spent a lot of time educating the market. We did some work last year with industry leaders across payer, provider, and health tech on defining the ethical uses of social determinants of health. There was a lot of consternation around how this data should be used.

At the end of the day, it is proven that health outcomes are driven just as much by your social factors as they are by any clinical conditions. It’s critical, if we are going to move to a value-based care system, that we treat people holistically. Their health, not just their clinical conditions. That’s what SDOH is for.

On the provider side, they are using it more from an HRA, health risk assessments, perspective. When you are signing in for your appointment, they’re utilizing information that they give you. They’re not using third parties as much. Some of the cutting edge systems are. We are seeing the third-party use more on the health insurance or the payer side, probably because of the scale. They are not as connected to their members, so they use that third party to get broader insights around population health for larger populations.

To what extent are health systems using outside data?

More and more. That is one of the great areas that we impact today. There isn’t a shortage of data, there’s a shortage of usable data. It is disconnected, siloed, and not standardized. That’s a big piece of what our business does, to help do that data standardization, data transformation, and the linking of that data to incremental data assets to help make better decisions in healthcare.

What are the challenges and imperatives around provider data management?

I was one of the founding members of Enclarity, a company that LexisNexis bought in 2013. We started in 2006 to try to solve provider data quality issues for the industry. Everybody is trying to keep that data up to date, and if every organization is trying to do the same thing, it’s terribly operationally inefficient. If we could do it in one place and leverage that across the industry, then we could do it better, faster, and cheaper for the industry.

We have been successful in being able to roll that out. We have large provider data management businesses across healthcare in health systems, hospitals, health insurance companies, life science institutions, and retail pharmacy.

The challenge is that providers move around a lot. US consumers move on average once every seven years, but the rate of provider change that we see in our MD and DO database is more like 24% per year. To keep up with that, you need to have systems that allow you to monitor, because providers are busy and they are not going to self-report in any meaningful way. We need to be able to monitor and use analytics to track and keep key demographics and key credentials up to date, which then allows us to process claims and have accurate directories for people to find their providers.

Provider data management and the resulting directories have turned into a consumer-facing tool that delivers competitive advantage.

Absolutely. You saw a couple of years ago that a lot of the attorney generals started making regulations around the accuracy rates of provider directories. They were saying that almost one out of every two providers listed weren’t accepting new patients, were no longer at that location, were no longer in network, or had a phone number listed that was no longer correct.

People were going on the exchanges to purchase their insurance, and the #1 driver of choosing an insurance plan outside of price is, do I get to stay with my provider? Almost 50% of the time, they were going to see their provider and finding out that they couldn’t. Then they had to choose between paying out-of-network rates or being disrupted by having to choose a new provider. In California, the AG likened it to a cereal company that lists false ingredients on the box. They put these regulations in place for consumers, not only for their access to care, but also for general continuity.

How are health systems using your systems and data in new ways, especially around the pandemic?

All of our solutions revolve around our three core data assets. They are differentiated proprietary data assets.

First is our provider data, which is the most correct current and comprehensive provider profiles in the US.

The second is the largest de-identified medical claims repository, about 2.2 billion medical claims. You can imagine not only being able to understand where a provider is and what their profile looks like, but now understanding what procedures and what diagnoses they’re doing at what location and who they are referring to, with all that transactional detail being linked. 

The third is more on the consumer side. LexisNexis is one of the largest aggregators of public and private data sources. We utilize that to create a large consumer data asset. That’s a highly regulated data set, but we can utilize it for patient safety. Linking data together from different data sites, making sure that we have high precision, and linking consumer health information together. 

We utilize it for protecting access to data. We do consumer authentication. Health data is yours. As a consumer, you own it. The hospital system doesn’t and the health payers don’t. But for you to get access to it, the covered entities need to make sure you are who you say you are. We have a sophisticated technology to be able to do that identity authentication.

Third is the profile enhancement, like you mentioned before, which is social determinants of health. I’ll give you one use case. During the pandemic, everybody needed to get tested, and now everybody is getting vaccines. We are at the front lines of that, doing the identity authentication. When you log in to check your test results, we’re authenticating that you are who you say you are. When you log in to make an appointment to get your vaccine, we’re doing instant identification of you to make sure that you are a real person so you can then log in to make that appointment.

You mentioned de-identified claims data. The trend is toward drug companies using real-world evidence and performing virtual clinical studies using provider EHR data sold them by third parties, which brings up challenges of data quality and ownership. What challenges do you see in the sudden rush to create a business of selling research data to drug companies?

You nailed the two challenges with it. They call it tokenization of the data. The de-identification of the data needs to meet statistical standards so that it cannot be re-identified. Certainly the SMART on FHIR HL7 standards will help create a better standardization of that data to make it more usable, but we are on the cusp of getting into that with the interoperability rulings coming into play.

Once it is de-identified, you don’t have the consent issue because it is no longer identifiable. But if the entity that is utilizing the data has identified information and they’re trying to link it to it, that can create some concerns as well.

From a hospital system perspective, there’s the new revenue stream of creating real-world evidence, real-world data assets, and leveraging them for life science companies. But I think that the next evolution is even greater, which is not de-identifying it, but  instead the hospital system, as a covered entity, is using it for real-time clinical decision support and clinical health pathways. We need a broader learning and research capability around how we are treating our patients. De-identification allows us to use data for clinical trials, but it’s even more valuable to be able to use it in interacting with our patients on the hospital and health system side.

Are providers using the “patients like this one” model to tap into broad evidence similarly how Amazon recommends an additional item because other customers like you bought it?

Absolutely. The cohort management of the like, I guess I’ll call it, is not only important for providers, but you are starting to see consumers want to be a part of that community and to understand that data.

I run the LexisNexis Healthcare business. Our sister company is Elsevier Health, one of the largest health content companies in the world. We have been doing a lot of work with them to  look within hospitals and health systems to see how they are using content related to those clinical pathways that you described for treatment, as well as for patient engagement. Upon discharge, how are we enabling those patients to understand more about their current health condition, how they should be treating it, and motivating and engaging them to be more in tune with their own health?

How widely are health systems using multi-factor authentication for security and applying technology to positively identify patients?

It’s going to be more and more of a concern. As interoperability enables the rate of health data exchange to go up, up, up, we are going to see the need for tighter data security and identity authentication go up, up, up as well. Some of the regulations have the NIST IAL criteria for authentication. Some of that requires biometrics, which we call TrueID on our side. It uses a driver’s license or a passport photo to verify.

There’s always a fine balance between compliance and enablement of the consumer. You don’t want to put them through such a security gauntlet where 50% of them give up and don’t end up logging in and getting access to the health information that they access. It’s that fine line. As a technology company, we want to enable it to be less abrasive to the consumer, but at the same time, enhancing the overall risk detection on the identity side.

You have seen that we’ve acquired several companies over the last few years, ThreatMetrix being the largest. ThreatMetrix is the largest digital identity network contributory database in the world that understands the IP address of your laptop and your phone. As you are logging in, we can say, “that phone belongs to Josh Schoeller” versus seeing that it’s routing through Eastern Europe. Doing bot detection, checking that the keystrokes are at the speed of someone typing instead of the same individual doing 136,000 transmissions in the last 30 minutes trying different access codes. All those things need to happen behind the scenes and in real time to help with security and to enable consumer access to their health.

How will vaccination passports work?

Every state has their vaccine registries. We work with several partners that interact with them and help them in various ways. All vaccine locations are required to submit to the federal registry.

The question is, will that become a consumer asset? We are seeing apps and companies pop up, saying that you can have your vaccines documented on your phone and pull it up when you want to go to a concert, get on an airplane, or send your kids back to school. There is definitely value in that utility, but the question is, what’s the commercial model? Will people actually pay for that access? If not, what’s the commercial viability of that space? Certainly this pandemic gave us all new kind of understanding. It changed the game as far as the importance of vaccinations and people’s access to them.

How has the pandemic changed the company’s business?

When the pandemic hit, we got together to say, what are the risks and what are the opportunities? We are a health business, and this is a health pandemic, so it’s going to be more impactful to us than other industries or other areas of the broader business.

We were able to look at how we could pivot into the needs that the pandemic created. Within three weeks of the offices shutting down last, almost a year ago this week, we created the LexisNexis COVID data resource. We put that out on the internet for free. That tracked every day all of the people who got COVID, using the Johns Hopkins data. We overlaid that with our claims data to understand hotbeds of comorbidities. We then overlaid that with our social determinants of health to understand other impacts to those communities. Finally, we overlaid it with our provider information. Where are the pharmacies, where are the hospitals that need to treat all these people? You could start to see hotspots of where we needed more resources. That was put out there to help the research community. Out of that, we interacted a lot with our customers around how they could utilize their data during COVID.

On the broader industry side, we were already moving rapidly towards digital healthcare, the digitalization and consumer-driven healthcare. COVID probably moved us five years ahead in that area. We saw a 400% increase in the use of telemedicine. That’s not going to go away. Consumers, because of all the news and all the information that was out there, generally got more engaged, and they did that in a digital way. That’s not going to change.

Our business needed to pivot to help both the consumer-patient-member as well as our customers, who are payers, pharmacies, and hospital systems. How we can help that digital experience — from a data security, compliance, and operational efficiencies perspective — improve health and healthcare delivery in the United States?

Do you have any final thoughts?

We are on the cusp, and we are seeing it every day, of healthcare transforming. It is consumer driven and digitally driven, but at its roots, it will be driven by the use of data and analytics to help drive better health care outcomes.

LexisNexis and other companies are in a unique position to help both public and private sector healthcare improve healthcare outcomes. That’s our mission and goal over the next several years. I’m bullish on us being able to improve healthcare delivery, as well as health outcomes, to create healthier communities across the US and being able to have the data and metrics to track that from an ROI perspective for our customers.

HIStalk Interviews Hal Baker, MD, SVP/CDO/CIO, WellSpan Health

R. Hal Baker, MD is SVP and chief digital and chief information officer of WellSpan Health of York, PA.

Tell me about yourself and the health system.

WellSpan is an integrated delivery system of about 20,000 employees over five counties in south central Pennsylvania. We’re locally governed and are committed to providing affordable healthcare in the region. We were formed through strategic affiliation of independent health systems in the region. We have a large medical group practice with multiple specialties and eight hospitals.

We went from “everything but Epic” to Epic in 2017, with our Summit Health recently going on Epic last October. We are finally on a unified electronic health record across our system and enjoying that in a region that has a lot of Epic. Care Everywhere provides good inter-system interoperability.

How are you using Nuance’s DAX (Dragon Ambient Experience) and what is the business case for implementing it?

I came to WellSpan almost 26 years ago and spent my first 10 years in education with the residency program. I’m still a practicing internal medicine doctor and I’ve been using DAX since the summer. I have found that it has dramatically increased my enjoyment of practicing and also increased my ability to concentrate on the patient. I’ve always been impressed that no judge tries to be their own court stenographer and no CEO tries to take their own minutes in a board meeting. We say it’s really not a good idea to try to text and drive, and yet all of our doctors are trying to text and treat.

That mental complexity of trying to handle the documentation and the invoicing of healthcare — creating the billable note with the HCC codes and the different number of bullets for the coding requirement — simultaneously while you are trying to listen to the person who’s telling you their problem and apply a thoughtful diagnostic acumen to it — that’s a hard juggling act.

In many other areas, we have said that that’s not safe. It’s the reason in aviation for having a silent cockpit from 10,000 feet down. In healthcare, we’ve tried to do that. I did not appreciate how much I was being exhausted by that until DAX came in and I had a virtual scribe through DAX that allowed me to just converse with the patient and stop worrying about the note. It seems like it would be a small thing that might increase my efficiency, but what I found is that I am so much more able to be present with the patient and to connect with them.

For me personally, I worried that it was because I’m an administrator most of the time, you’re always thinking about other things, and you have that executive halo sitting on your shoulder that’s watching. You’re more distracted than other doctors might be. But one of our urgent care doctors was on a call discussing our efforts to reduce burnout in our providers. He gave me permission to read this in the meeting. He wrote to people:

“It hit home with what I started yesterday. I started a demo of the DAX system. I was very skeptical prior to using it, which is why I was probably chosen to demo it. I consider this a game changer. Over the past few thousand patient encounters, this is the first time I could literally sit and talk with the patient without being preoccupied. There was a clarity during the patient encounter because I was not busy typing. I think this is going to be a game changer. It’s unfortunate we have made patient encounters so incredibly busy that we are now trying to revert back to the way medicine was and should be.”

He captured what I was feeling, so I asked him if I could use that quote. But it was nice for me to see that it wasn’t just me who perceived that.

Is the result immediately available following the encounter or is there a delay as behind-the-scenes humans complete the work? Do you have to make a lot of corrections?

I started out my career writing my own notes and handwriting, which was a primitive form of encryption, but pretty effective at that. I then came into my faculty practice. I was able to dictate. I still had to listen to the patient and then regenerate the note. I then moved to Dragon because it allowed the note to be present at the end of the visit, something Dr. Jayne commented on. I really liked that and Dragon was certainly good enough. We have deployed Dragon in the exam room.

I have always dictated in front of patients because it lets them correct me and it lets them hear that I’ve listened to them. I get the notes back in four hours. We’re one of the first places to apply it to primary care. DAX was developed in orthopedics. I have gone through being a patient with a doctor doing a DAX orthopedic visit. I threw in some obnoxious things just to see what would happen and got a note back within a few minutes from the AI. It wasn’t perfect. It would have needed some editorial tweaking. But it was remarkably on target for a conversation being converted into medicalese.

What we’re seeing now is that four-hour turnaround time. I only am able to review a certain number of notes before I leave for the day and I have to do some the next day. But it’s worth it for me to be able to be fully present with the patient. Some providers really like the note to be absolutely their note and others of us are OK with somebody else writing the note as long as it got the key facts and is basically telling the same story.

I will say that the DAX notes are high quality. They’re not exactly as I would have written them, but I don’t think they are inferior, and my partners don’t think they’re inferior when they read them. But relieving me of that responsibility of mental note-taking and compiling the note in my head while I’m trying to listen and think through the problem — that’s been a win. I would say that some doctors really want the notes to be their notes and it may not be for everybody. But if you can let go of the perfection of it being your note and allow a good process to generate a note, I think it’s doing a great job. And there’s something to be said that I underappreciated about relieving the doctor of the invoicing part of medicine and just having them focus on the clinical part.

We are rolling out a pilot of 50 doctors. We absolutely know we need to make the business case. We’re going to be looking at employee and patient satisfaction, pre- and post-DAX versus DAX versus control group, people doing the old way. We are also hoping that there’s some improvement in efficiency by removing the time that you had to re-dictate the note, essentially. I only spend about 75 to 90 seconds reviewing and signing a note. I clocked myself because I knew I would have this conversation with you coming up. So it’s certainly faster than me dictating, but we are looking for that business case you talked about in your blog a week or two ago. We don’t have it yet, but we know we need it to justify a further rollout.

So your business case will mostly focus will be on patient satisfaction and recapturing the patient-physician relationship in being able to look each other in the eye instead of the physician typing?

We are looking at everything we can think of that might indicate value so that we can justify the investment in DAX. As the AI learns how to write notes from the combination of AI and scribe, the timing will get shorter over time. We’re committed to being early and we are training it. It’s much further along in orthopedics than it is in primary care. The vocabulary range in primary care is huge compared to orthopedics, in terms of what we talk about in an encounter. That’s a challenge, but we think it is already bringing in value.

I was named one of the top 10 doctors for patient satisfaction recently. I think that’s the first time I’ve been called out for that, and it was while I was using DAX. That’s an N-of-1 result, but I’m wondering if the two are related. That’s part of the reason why we are studying it.

How is the health system addressing consumerism and patient relationship management?

That’s a very dedicated part of our effort. We want to become easier to use and reduce the friction of healthcare.

Like many people, we have had a rapid rollout of video visits. We’ve been very active in online scheduling. A woman can schedule her mammogram without an order, go in and get it, get her report back that evening, and click in and look at her mammogram images on our portal. We made a commitment long ago to put in the portal that we wanted when we were patients, even if it wasn’t the portal we were always comfortable with when we were providers. We give access to adolescents up until age 18 to the parents unless there’s a special court situation, which is something a lot of people have shied away from. We gave people access to their images online. We did that in February last year, then COVID happened and we completely blew up our marketing plan for communicating it. People still found it and we got to over 40,000 images viewed per month.

We are trying to get people where they are and offer them the services so that they can interact with us with the least amount of friction. We are experimenting with Livongo with our employees. We just managed to integrate it with Epic, which was a nice cooperation between Livongo and Epic.

What were your expectations in replacing everything with Epic and what opportunities have resulted?

We had done a lot of work to put the Allscripts notes into Cerner and the Cerner notes into Allscripts to make sure all the imaging results were available in both. But the ability to coordinate through secure chat with specialists … Johns Hopkins is down the road from us and we have a partnership with them in oncology. For me to be looking at a Hopkins pathology result from eight years ago in about five clicks from the Epic record is fantastic interoperability. I dramatically underestimated how good that would be.

For us to have a patient go from one of our hospitals to one of our offices and not have to start over is part of our promise to make you feel like we know you. We have a effort we call “Know Me” to make people feel like we know who they are. For instance, the name “Levine” can be pronounced three or four ways. We have a section in our record in our Epic storyboard where we have the pronunciation so we know whether to say lah-VINE, lah-VIN, or lah-VEEN.

How do you see technology’s role in clinical and quality improvement?

This is kind of a hard concept, but our work in sepsis was so successful because we leveraged humans through technology. Rather than having a sepsis alert fired to busy ED doctors and nurses and reminding them with pop-ups that at best have about a 20% response rate, we instead fired it to a nurse who was watching over every patient in the hospital and figuring out whether that was a real problem or a false alarm. Then going to see if the team is doing everything they’re supposed to do. Not picking up the phone unless there was something that was being missed. But when they did call, the teams in the ED and the ICU quickly learned that eight out of 10 times, it was going to be a real situation.

That was a known person calling with a worry. They have actually done some research, looked at the chart, and said, “I think we’re missing sepsis here” or “I don’t see that you’ve ordered the fluids at the right rate” or “the antibiotics haven’t come down from pharmacy” and allowing us to rescue the sepsis bundle. We were able to get up to 90 to 100% compliance. With that, we are able to achieve O/E ratios — observed to expected deaths — of 0.6, 0.7 in some of our hospitals, our mortality saving over 200 lives in a year.

It was awesome when we received the Eisenberg Award for patient safety and quality for that. But I think if we tried to do it all with technology, it wouldn’t have worked. It was partly having that human voice in looking at the alerts and translating them into real or false alarm and then calling with an explanation of why I’m calling you and what you need to do in a trusted relationship. The magic part is when you put human beings with technology to create a trusted communication.

Is there an organizational effort to get rid of perceived barriers that give health systems the reputation of being impersonal, bureaucratic, and inaccessible for patients, physicians, and employees?

Absolutely. We borrowed the, “Get Rid of Stupid Stuff” from Hawaii Pacific Health. We are trying to do that. Our vision is as a trusted partner, reimagining health and reimagining healthcare and improving health. But that trusted partner thing is really important to us,. That’s what we commit to.

Our mission statement starts off with working as one. I think that is probably our biggest catch phrase — we want people to feel like we are one team, even if we are multiple offices. We’re not perfect by any means, but there’s a consistency of that exploration. I suspect that any WellSpan employee who is standing in a line in an airport hears somebody say, “That was a time when we really did a good job of working as one,” they would turn around and wonder if that was a WellSpan person, no matter where they are.

What projects will be most strategic over the next few years?

Trying to improve the efficiency of healthcare and reduce the cost. I’ve been intrigued with Livongo. Maybe we can take care of people with hypertension and only see them in the office every few years. Now that we have that integrated into Epic, it’s been really interesting to think about. With COVID, within 34 hours of the governor’s announcement, we had turned on COVID vaccine signup and had over 46,000 people signed up. You have to be ready and be able to move quickly when those kinds of things happen.

We’ve had over 100,000 people sign up for our portal in the last two months. A lot of that has been driven by COVID vaccinations. It’s up to us to retain that user who came in for one purpose and try to establish a trusted relationship that allows them to use us in an easier way online or wherever, by whatever means they want to use us with. We take care of the Plain community here, which you would probably call the Amish, so there are practices in WellSpan that have a hybrid charging station next to the hitching post. It’s all about meeting our community where they live.

HIStalk Interviews Ann Barnes, CEO, Intelligent Medical Objects

Ann Barnes is CEO of Intelligent Medical Objects of Rosemont, IL.

Tell me about yourself the company.

This is my 13th year of running healthcare companies, both on the services and now on the software side. IMO is a fun company that was founded in 1994. The founder’s vision was that software companies and technology companies that wanted to make a difference in healthcare had to think like doctors and clinicians. Everything we do at IMO, both with terminology and data insights, stems from giving clinicians and doctors what they need to be able to get off the computer, stop focusing on that, and instead focus on patients. Then, how we can help provide better data and better insights to improve patient outcomes.

What are the terminology challenges with interoperability and aggregating data from multiple hospitals?

Terminology is not static. It is constantly changing. You need clinicians to keep terminology current, which is hard for hospitals that try to do it on their own. We specialize in not only keeping the terminology current, but adding new terminology as it becomes necessary for the medical field. COVID was a strong example. We started in January working side by side with the CDC in adding new descriptors and terms so that physicians could describe the symptoms of COVID differently than they were describing the symptoms of the flu. Otherwise, it would all look the same.

Does demand exist, beyond public health, for immediately retrievable patient information that originates in hundreds or thousands of hospitals?

Yes. Probably one of the biggest challenges across healthcare right now is that as data is aggregated, details are lost because it is not standardized or it’s coded. Somebody wants to get back to that level of specificity about a patient or about a group of patients that they are monitoring or trying to find, but that is difficult once you get back at the granular level.

We are fortunate at IMO that one of the initial values of our product is that we let physicians speak physician and write something just like in Google, any way they want, and we make sure they have the freedom to document how they want. We translate that to 24 global code sets, but more importantly, we maintain the specificity of the data so that it can be unlocked on the other side. We are spending a lot more time thinking about insight products and how to normalize the data that’s coming out of disparate systems and then pull insights from that data in an easy way that is maintained and updated.

At least we didn’t force physicians to do their own manual terminology lookup and translation for someone else’s benefit, as was done with other scribing chores.

Exactly. Clinicians don’t want to have to think about what the data is going to be used for downstream. They are focused at that time on the patient and describing as specifically as possible what is going on with the patient and any sort of diagnosis. Whether that data is being used for reporting, billing, or quality reporting doesn’t matter to the physician. They are trying to capture the data and take care of the patient who is in front of them.

As value-based care increases and the focus on patient outcomes increases, that intensifies. We are trying to take off the plate of that physician the worry about what’s going to be done downstream with this data. Let’s capture the specificity as you want to share it.

Has the challenge become easier with consolidation in the number of EHRs being used?

We actually we see the number of EHRs increasing in health systems. They will have Epic, Meditech, or Cerner, but then they also have an ambulatory EHR, behavioral health EHR, or other EHRs in their clinics. The are sitting there in their health system trying to pull data.

COVID was again an example. Health systems were struggling to find the COVID-symptomatic patients or the COVID-positive patients with underlying conditions across the health system. That is one of the reasons we released some free COVID insight products during the timeframe to help our customers do that. We released terminology for free, open source terminology for non-IMO customers, so that everybody could be speaking the same language.

You have a couple of challenges. You have the systems being used. You have the terminology that is the base in that system. Then you have how it was implemented. All these complicating factors make it difficult if you can’t pull that data out, normalize it, and then pull insights from the normalized data.

Why is it hard to get a list of COVID-diagnosed or COVID-positive patients?

It’s easy to get a list of diabetic patients. But it’s harder if you are looking for Type 1 diabetic patients with BMIs over a certain level who have retinal problems.It’s more difficult to search disparate data systems. The way that those diagnoses are described continuously changes. It’s not good enough to create a group, or a cohort search, once. You have to constantly maintain and update it so that you are capturing all of the patients that should be in that cohort. That makes it difficult.

Does it take a lot of coordination and discussion to populate research databases using data from many hospitals?

Yes. It generally takes a back-end tool. We are finding that across healthcare now, beyond the hospitals, there’s this large need with data aggregators, top health companies, HIEs, and point-of-care solutions. Anybody who’s pulling from that same data has the same challenges. Each use case is different, but they are all trying to do the same thing. They are pulling from multiple platforms and multiple ways of describing things.

How much progress has been made so that a healthcare startup can get hospital data that is immediately useful, even if only from their own client?

It’s an enormous problem. For a while, people tried to rely on coded data or claims data, which is summarized data. It’s good for the purpose it was summarized for, but it doesn’t work when you get back to the specifics of a group of patients or a patient themselves. A lot of effort is being done across the industry to make this better. Our EHR partners are working on it and we certainly are. We launched a product last year called Normalize that allows an entity to normalize the clinical data and and then pull insight from that data. The way things are described is standardized.

Was it hard to get a historical picture of COVID infection after the fact once code sets were finally updated?

It was difficult, but that’s why we focus so much on letting the physician describe it clearly and specifically. We can go back to the specificity that the physician used in the description to sort through that. But it is much, much more difficult.

That’s why 2020 was an interesting year for us. We generally do four to six terminology releases per year for our customers. We had releases going out every single month because so much was changing with COVID and we needed to get the descriptors in there as quickly as  possible. Each time there’s a new learning, we have to get those descriptors in so that the data is a little bit cleaner early on, and you’re not trying to go back for as many months.

What have we learned from the need to get near real-time hospital data for urgent research?

We have learned, especially in a pandemic year, how critical it is to get the right information into the right hands of the right people and make sure the tools they are using can support it quickly, so that you can take care of the patient and create better patient outcomes. That isn’t happening, as you said, in the old traditional ways any more. There’s much more need to create networks of information and ways to disperse that information out to clients as quickly as possible. Not just from a company like IMO, but from many vendors in healthcare IT, who are working side by side with our hospital partners and with physician organizations across the country to make sure the information is shared, is accurate, and is complete and up to date.

How are health systems using value sets?

Value sets are searches that allow you to filter to find a specific cohort or group of patients. Then, to monitor them, reach out to them, and communicate with them.

Hospitals are using them in many ways. They are using them proactively to reach out to patients, such as in the vaccine situation, where you are trying to find a specific group of patients. They are also using them after the fact to monitor patients and do post-communication or information sharing.

It becomes critical to create these value sets accurately and to include all of the specific descriptors, not just the code sets. That changes every month, as in COVID, where we were changing descriptors and information and adding new information every month. You have to maintain those and update those to continue to be accurate. It’s not a one-time event. Not just hospitals, but others in the industry are using those as well, to monitor groups of patients or find information on groups of patients at a more specific level than a high-level search, as I described earlier.

Has the need changed from retrieving a set of patients whose characteristics support a research hypothesis to instead hoping that technology, perhaps using AI or other techniques, can take a seemingly diverse group of patients and figure out what risk factors and outcomes they share?

AI and other technology is useful, as long as you maintain the specific information. Searching or using AI on summarized or aggregated data doesn’t work because you have the same problem as if a human was doing it. You can’t find the information. You have to make sure that the specific information is in there and that you are using some common language. Words become important and descriptors become really important so that you can pull from both the structured and unstructured data in the same way.

The biggest challenge, still, is the common language. But as we continue to create tools that can standardize that language and can normalize that data, then there’s an opportunity to start to use more technology to mine the data.

Here’s an unrelated question about your interest in creating opportunities for women in health IT and business in general. I can go to Company X’s leadership page and see rows of white male faces. How would you convince that company that the people they chose for those jobs weren’t optimal?

So much of it is awareness and being intentional. I spend a lot of time talking to different groups about this. I can tell you that first, the leadership has to recognize that diverse teams outperform non-diverse teams. Helping them understand that and showing them proof sources of where that’s really true makes sense. This isn’t an indictment of, “Hey, men can’t do it.” It’s just that men can do it and women can also bring a unique aspect to it. When you are serving something like healthcare, it’s obviously made up of many, many women as part of your decision-making. You are missing out on the unique opportunity to deliver what you need to, to an audience, if you aren’t looking at it from a diverse perspective, which actually goes way beyond men and women. It begins with believing that.

Once you believe that, stop talking about it and turn it into action. Many companies are good at executing, mine included, but if it isn’t a focused goal that you are executing on, then like anything else, it’s just a theoretical, conceptual conversation, and maybe it happens and maybe it doesn’t. Because women are so underrepresented, you have to be intentional about your hiring process, making sure that the candidate pools are diverse, because if the candidate pools don’t start out diverse, it’s difficult to get diverse hiring decisions.

I focus on it being intentional. I was intentional with how I built my team. I was intentional about specifically putting a female in the CFO role because we had a strong cultural belief in the company that men were CFOs and women ran HR. My chief people officer is a man, intentionally, and my CFO is a woman, intentionally. I found incredible candidates just by making sure that the pool of candidates was diverse.

So white men often get these jobs because somebody down in the company pushed them to the forefront as candidates?

That’s right. There’s a larger pool of those candidates. I gets even even more challenging when you race to that mix. We all have a responsibility to reach out to the college age kids and the high school aged kids, because we don’t have enough women. We don’t have enough black or Hispanic students going into majors around STEM, going into focus job opportunities or internships around STEM. You also have to get intentional about helping make a difference to help the candidate pools get better over time. We focus an intern program there to help our candidate pools become richer.

This definitely isn’t about hiring a lesser candidate. Nobody should hire a lesser candidate for the job. You need to hire the right person for the job, but it starts with having diverse pools of candidates to choose from.

Where do you see the company focusing in the next 3-5 years?

We will continue to grow terminology. More and more needs to be added, but we also will begin to focus more on the insight space and on new markets that need that. The way that I look at the ecosystem is that there’s this large pool of clinical data. No matter where you are in the ecosystem, everybody is pulling from that same data. There’s not a different data set somewhere else. There’s different use cases driving the need to get at that data, but there’s a variety of people — some that I described, some in the payer space, some in life sciences — who are all pulling from that same clinical data. I see an expansion for opportunity for IMO to help expand in the terminology space, but also expand who we are helping in the use cases we can provide solutions for, to actually accomplish more from the data.

Do you have any final thoughts?

We are improving in healthcare. As challenging as COVID was for the whole world, it put an exclamation point on where there are holes and where we need to make improvements. There’s a lot of opportunity for healthcare IT technologies to come in and fill some of those gaps. I’m excited about the movement in healthcare and the movement towards patient outcomes and the actual fact that the data can and will support it as we move forward.

HIStalk Interviews Mary Kay Ladone, SVP, Hillrom

Mary Kay Ladone is SVP of corporate development, strategy, and investor relations of Hillrom of Chicago, IL.

Tell me about yourself and the company.

I am an executive with more than 30 years of healthcare experience in a variety of areas — finance, financial planning, operations, strategy, corporate development, and investor relations. I am also privileged to serve as a member of the board of trustees for Edward-Elmhurst Health, which is one of the largest systems in the Chicagoland area. I have been at Hillrom for just about five years after spending most of my career at Baxter International and its spinoff Baxalta.

I am happy to be a part of the Hillrom team. Hillrom is a medical technology leader. We have a diversified global business, with $3 billion in revenue spread across three businesses — patient support systems, frontline care, and surgical solutions. Hillrom’s portfolio spans all care settings — acute care hospitals, ambulatory or physician care, and the home setting.

I couldn’t be prouder and more excited to share with you some of my perspectives on our connected care strategy and how we continue to accelerate growth and drive value for our patients and caregivers. We are focused on executing on our strategic priorities and advancing our vision.

Some people might be surprised that the company’s home page highlights “advancing connected care” rather than hospital beds. What business units support that concept?

Hillrom has historically been known as the leading bed company, but if you have followed Hillrom over the last several years, you know that we have significantly diversified our portfolio. We have strengthened our business model and established a strong track record of performance. All of which has led to a pretty exciting and compelling transformation and transition of Hillrom into a medical technology leader. For example, today our hospital bed portfolio accounts for just less than a quarter of Hillrom’s total revenue versus about 50% of our total revenue 10 years ago.

Our vision of advancing connected care is tied directly to our mission of enhancing outcomes for patients and their caregivers. It is integral to everything we do across all three of the businesses. Our primary goal is to collect data and to turn that data into actionable insight that allows for real-time interventions and enhances patient outcomes.

Our connected care efforts are focused primarily on improving workflows, lowering costs, and improving diagnosis and patient care. We estimate that there are over 1.3 million Hillrom devices in the field that can be connected across a variety of the care settings, including acute care and surgical environments, the ambulatory or physician office setting, or in the home. Our diversified portfolio includes an ecosystem of smart devices, including our smart beds, communication, and connectivity solutions. We have sensors and devices that can continuously monitor patient vital signs. We have a suite of diagnostic tools. We have respiratory health products that are used in the home to treat cystic fibrosis and other respiratory diseases, such as bronchiectasis and COPD.

What is involved with turning a large amount of medical device data into information that a clinician can use for real-time decision-making?

We are continuing to invest — in both our internal R&D programs through organic innovation and through external or M&A — to build an ecosystem of connected devices that will put actionable information in the hands of the caregivers. You don’t want to overwhelm the caregiver with too much information, because that makes it less actionable and less valuable to them.

An example is the launch of our digital offerings or algorithms later this year that will target two of the most costly non-reimbursable expenses for the hospital — patient deterioration and patient falls. Our value proposition with these algorithms is focused on lowering hospital costs while increasing quality and enhancing outcomes.

In terms of patient deterioration, we are utilizing our EarlySense sensor. This is a contact-free continuous monitoring sensor that monitors heart rate and respiratory rate 100 times per minute. This data is then collected and aggregated. The algorithm can provide an alert through our mobile communication platform that provides for early detection and intervention at the first sign of deterioration. This is important, as patient deterioration or sepsis is an expensive complication that costs the healthcare system more than $20 billion annually. The earlier the intervention, the more likely the ability to achieve a better outcome at a lower cost.

Another example would be our Excel Medical acquisition, which brought to us medical device integration capabilities as well as waveforms that can be visualized on the mobile device. It also provided us with an alert and alarm management system. This system is set up to prioritize alerts, organize them, and send them to the caregiver in a prioritized fashion so that they can act on the most important of those alerts. It helps them improve their workflow and improve the workflow efficiencies across the healthcare system.

The acquisition of Voalte gave Hillrom a solution that includes devices, integration, and communication. Does that provide a competitive advantage given the importance hospitals place on reducing vendor count and complexity?

Yes. We have actually done two acquisitions in the area of care communications. You mentioned Voalte as an example. We have traditionally been the leader in the traditional nurse call systems for our acute care customers, but in doing so, we have realized that we could accelerate our connected care strategy by building on this leadership position and creating an ecosystem of solutions that leverages our smart beds as the hub for communications data and connectivity.

The acquisition of Voalte and then the acquisition of Excel Medical that I just mentioned differentiated Hillrom as the only provider of a comprehensive mobile communication solution that provides voice, text, alert and alarm management, digital wave forms, and medical device integration. You are right that it is important that our acute care customers can buy that one solution from one vendor and not have to piece it together and tape together a variety of solutions from a variety of vendors.

The pandemic has increased the use of remote patient monitoring, both in hospital areas that weren’t previously equipped for monitoring as well as the home. Will that have permanent impact?

Hillrom has been a leader in traditional patient monitoring within the acute care setting with our vital signs monitoring devices and other devices that we’ve integrated into our smart beds, like the EarlySense sensors we just discussed that monitor heart rate and respiratory rate. We also have a WatchCare device that monitors incontinence events and can help reduce infection and pressure ulcers. But you’re right, the pandemic has also highlighted the importance of remote monitoring capabilities, and this is one of our core focus areas as we look to shift care closer to the home.

I can give an example of one of the opportunities that we embarked upon at the beginning of the pandemic. Our company quickly pivoted our R&D efforts and we introduced what we called our Extended Care Solution, which combined our Spot 4400 Vital Signs device with a patient app and a clinical review portal to help extend patient care beyond the wall of the healthcare facility. Clinicians can access the patient’s temperature, blood pressure, and Sp02 measurements. The patient doesn’t have to be in the hospital setting. They can do this at home, and that provides an enhanced level of care. This is a trend that is accelerating given the pandemic, and one that we continue to look at both from an internal R&D perspective, but also from an M&A perspective, as a potential opportunity for Hillrom going forward.

What will be the company’s most important areas of focus in the next 3-5 years?

I think it goes back to our strategic priorities. One, about being a category leader across our various portfolios and businesses. We want to continue to expand internationally and penetrate emerging markets, where today our exposure to emerging markets is under index relative to our peer group.

We want to continue transforming our portfolio. We have recently exited some lower-growth assets and we have been turning to M&A as a key driver for future accelerated growth.

We have also been experiencing and demonstrating a strong track record of performance and operational excellence, during the pandemic in particular. We have stepped up to help our hospital customers during this difficult time.

We are focused on what we consider our core growth platforms. These would include the areas of care communications, respiratory care, patient monitoring, and surgical kinds of activities. All these care categories represent attractive markets and areas where we believe Hillrom brings capabilities as well as a competitive advantage where we can win. These are going to be the areas that will drive our success in the future.

Do you have any final thoughts?

The transformation we have seen at Hillrom from a bed company 10 years ago to a medical technology company today is exciting. It has been compelling. We have doubled our size in terms of revenue. We have rebranded the company. We have our vision of advancing connected care that we are all focused on, driving the growth across our key strategic growth platforms in areas that we believe are addressing some of the healthcare system’s biggest challenges. We hope to bring comprehensive solutions to the table that help our healthcare customers and caregivers and enhance patient outcomes over the long term.

HIStalk Interviews Michele Perry, CEO, Relatient

Michele Perry, MBA is CEO of Relatient of Franklin, TN.

Tell me about yourself and the company.

Relatient is the 2020 KLAS category leader in patient outreach and communication. The company is located right outside of Nashville, TN. We got our start with appointment reminders back in 2014. Since then, we have built an entire patient engagement platform to help medical offices manage all the major touchpoints in the outpatient journey. Our goal is to end phone tag in healthcare.

I’ve been Relatient’s CEO since 2017. We have been growing a lot and we are excited about where we are headed as a company and the work we are doing alongside the health systems, hospitals, and medical offices we serve to improve the patient experience.

How are providers using technology to manage COVID-19 vaccinations?

Medical providers are really grabbing hold of technology right now to solve the daily operational issues related to getting the COVID-19 vaccine distributed on a mass scale.

The first thing we started hearing from health systems like Med Center Health in Kentucky and Warren Clinic in Oklahoma was that they wanted to shoot for zero wasted doses. When they came to us with those conversations, they were most concerned about patient no-shows, because the first vaccine was Pfizer’s and the whole freezer situation meant that once a vial was thawed, mixed, and ready to use, it couldn’t be set aside for another day. A patient no-show could mean doses in the trash, and no one wanted that. After they set up their vaccine departments or clinics and locations, we configured some specific vaccine reminders to help get patients to both the initial appointment and the one following it 21 days later.

Health systems learned really fast that getting the vaccine schedule filled was a huge task. It takes a lot of people to work through lists of patients who qualify and get them booked. We had used our patient self-scheduling module for some customers earlier in the pandemic that wanted to let patients self-schedule for testing. We turned this on for customers who asked for help with vaccine scheduling and then made it available for new customers, too, turning it on very quickly un-integrated for immediate scheduling.

Some other things we’re seeing providers do include the use of messaging tools to send mass communication to their patients and their staff, like when a new phase of vaccinations opens up or a new vaccine clinic. We’ve seen them use short links to maps and directions in case patients are new to their organizations and utilize text messaging for one-to-one patient conversations so they can field questions and make schedule changes without the back and forth of playing phone tag with patients.

Why do patients fail to show up for their appointments and what are the best practices to reduce the no-show rate?

It’s interesting, because we are far enough into a world where appointment reminders are the norm that patients have come to rely on them to remember and plan for their appointments. Healthcare has come a long way in this, but COVID-19 introduced a new layer of complexities to patient schedules and the load of responsibilities patients are carrying. They’ve got kids at home all the time, they’re trying to work from home, they may no longer be close to the doctor’s office during the day because of this. We have heard from a lot of healthcare leaders over the past year that patients who were afraid to come in early on added to no-shows. It kind of all comes down to keeping communication open and clear so patients know that you are open and you’re a safe place to receive care. If something changes, do they have a telehealth option that can replace the in-person appointment?

The other key piece or best practice is the combination of communication methods and the ability for a patient to respond to a reminder. We’re patients ourselves and we get reminders from our own medical providers that either don’t ask for our confirmation or response or only allow a confirmation. If a patient has to call your office to cancel an appointment, they’re likely to hit the phone tree or get put on hold and hang up. This is where a lot of patient no-shows still come from, and there are well-established practices to avoid this.

Patients want self-scheduling and virtual waitlists more than just about any other technology. Has the pandemic affected adoption?

Definitely, and for a few reasons. Part of the increase in adoption has been resource constraints. Medical offices had to furlough employees, like many other industries. When they started to recover from that, they got hit with COVID-19 cases of their own and often found themselves short-staffed. The need for self-schedule and waitlists that can backfill last-minute cancelations is growing as there are fewer resources to do these things manually.

Additionally, Accenture recently reported that two-thirds of patients said they are likely to switch providers who don’t meet their expectations for handling COVID-19, and we know that patient access is a piece of these expectations. More than 30% of patient appointments are scheduled after normal clinic hours.

As I mentioned earlier, managing vaccine and testing schedules has also been a big burden to medical practices. Solutions that can lighten this burden and empower patients to self-select are win-win.

Can medical practices compete with the consumer-facing technology that is offered by urgent care centers, health systems, and chain drugstores?

Absolutely. Medical practices have the potential to offer the most personalized care if they can keep up with the innovation of larger organizations. They can do this with a cohesive digital strategy that works alongside and enhances their portal strategy. When solutions aimed at expanding access and convenience — like self-scheduling, two-way patient-practice conversations, and registration — are only available to portal users, a significant portion of a provider’s patient base never experiences those benefits.

Which health IT sectors will be the winners and losers in the next few years as COVID-19 becomes better controlled?

This is the winning question, right? COVID-19 won’t be a crisis forever, but some of the things we’ve learned during this time will stick around long term and we’re better for it.

Telehealth is one that is here to stay, but it won’t stay at the levels medical providers have used over the past year. Providers are now operating hybrid care models, where patient care is delivered in-person and via telehealth, so they need tools and workflows to help support this model of care delivery. I expect telehealth vendors to continue refining and expanding their technology as medical providers lean away from general video conference platforms that filled the immediate need early on.

The health IT sectors that help answer the question, “How do we get patients the right care, in the right place, at the right time” will be the winners. Interoperability will be a must as care becomes more dispersed, and digital communication tools and patient messaging will be crucial to helping patients navigate the journey.

You kind of hit on this already when you asked about consumer-facing technologies, but it’s key because patients are consumers, and these are the tools and kinds of access they’re looking for. My point is those technology sectors that require a lot of the patient — apps to download, portals to log into, additional accounts to create, and passwords to remember – will find less and less room over the next few years.

HIStalk Interviews Lissy Hu, MD, CEO, CarePort Health

Lissy Hu, MD, MBA is co-founder and CEO of CarePort Health, powered by WellSky, of Boston, MA.

Tell me about yourself and the company.

I’m a physician by background. CarePort connects hospitals with post-discharge providers, such as nursing homes, home health agencies, hospice, community-based providers, and all of the services that patients need after a hospital stay.

What activity are you seeing around hospitals sending ADT notifications to the patient’s other providers now that the deadline is getting close?

We’ve spent the last couple of years helping hospitals and post-acute care providers navigate that initial transition from the hospital into post-acute. Instead of a fact-based or manual process, where the discharge planner at the hospital picks up the phone and calls around to all the different nursing homes in the area asking if they have a bed, we have a network of hospitals and post-acute providers on our platform that can send these referrals electronically and that can communicate back and forth.

Over the last two years, we’ve seen more interest in closing that loop or that round trip. For the ADT piece that you referred to, not just how to get patients out of the hospital efficiently and share information back and forth in that transition, but being able to understand, when a patient lands in a skilled nursing facility, how long they are there, especially if a patient then goes back into the ED or gets admitted. We are seeing a new level of collaboration between acute and post-acute, especially as folks are starting to realize the importance of post-acute and how much that drives outcomes, both from a cost and quality standpoint.

We’ve learned that open hospital beds aren’t managed like a grid, where COVID-19 patients are moved between hospitals based on individual hospital capacity and clinical capability. Are hospitals showing an interest in sharing open bed information with each other?

On the bed availability piece, you are right. There’s not a centralized information piece out there, and we are seeing more interest in wanting that level of visibility. We are seeing it not only on the hospital side, I would say, but interestingly, on the post-acute side as well.

One of the things that has been so interesting about COVID-19 and the pandemic is that we sit in the middle, in terms of the hospital and the post-acute. We see the impact on both sides. Even in April and March of last year when things were really kicking off in the New York area, what we were seeing was that the hospital capacity and their capacity to take patients is very much tied to their ability to discharge patients into that next level of care, in terms of that post-acute.

People will start to see that it’s not just about the hospital bed — it’s around capacity and that flow across the entire continuum. New York hospitals were having a hard time getting their patients out of the hospital and into post-acutes, because a lot of these post-acute providers changed their admissions policy with COVID-19 in their vulnerable population. That hesitation to take on new patients backed things up from the hospital. What I’ve been encouraging our customers to think about is that visibility into the hospital beds is helpful and it’s necessary, but you also need to think about that next step. Where does that patient go? Because it is a pipe that’s connected.

We also saw in New York a high number of nursing home deaths that were possibly caused by forcing them to accept their residents back into the facility following discharge from a COVID-19 hospital stay. How will that situation change permanently and will technology play a part?

That highlights two things. First, the interdependency between hospitals and post-acute providers. It also highlighted to a lot of people the dual roles that nursing homes play in our society.

On the one hand, they are residential facilities for the elderly, the vulnerable, and those who can’t be in their own homes, so they are these long-term care settings. On the other hand, we rely on them as post-acute settings, where folks who have gotten a hip or knee replacement or are recovering from surgery go for a couple of weeks, almost like a step-down unit, to recover, to rehab before moving on to home with home health or back into the community. That was the challenge of New York and really all across the country — we need places for people to recover that aren’t the hospital.

At the same time, these facilities traditionally have been these residential facilities for the elderly and the vulnerable. How do we balance that? Does that get split apart? The role that technology can play is facilitating that transition as much as you can with high-quality information. In our products, we looked at facilities that could take COVID-19 patients, that had a separate wing, isolation wings, and a separate admissions processes. We tag those in our system so that the discharge planner at the hospital will know. We transmitted COVID-19 results that were pending from the hospital to the post-acute care provider.

Those were all COVID-specific changes that we did in part because we had to help our customers, but also because the market is moving to increased interoperability between the hospital and the post-acute care providers. There is a need to share more and more information, especially as we are seeing sicker and sicker patients going into post-acute because of length-of-stay pressures in the hospital.

Your product helps hospitals and families select a skilled nursing facility, with CMS star ratings being one factor. Were those ratings predictive of which SNFs had a lot of COVID-19 deaths, and will consumers look at different criteria after the pandemic is controlled?

The biggest change we’ve seen is a shift away from facility-based care towards more home-based care. There have always been patients who clearly need to go to a facility, or who clearly can go home. But in the middle ground of patients are those jump ball patients that could go home, but maybe they are just sick enough or frail enough that they need to go to a facility. We’ve seen a lot of this shift, where patients who might have gone to a facility in the past are now going home.

The other change is that going home instead of to a facility is a more difficult discharge. When you go to a facility, you’ve got your dialysis, you’ve got your infusion, you’ve got your nursing care. All of that is set up for you. When you go home, the discharge planner has to set up all of those pieces a la carte.

We saw hospital admissions go down, so we were expecting referral volume to go down. We found that when we looked at 2020, our referral volume went up by almost 20%, even though total admissions to hospitals were down. I think a lot of that can be explained because of the complexity of setting patients up at home and the need to set up more and more services. A lot of people are saying that COVID probably accelerated some of that, but that trend of more patients opting to go home was already there.

That was a  roundabout answer to your question about whether patients are picking facilities differently. The shift to home was probably the number one trend that we saw. But in terms of patients picking facilities differently, I think people are paying more and more attention to the quality of nursing homes. COVID highlighted some of the problems with those ratings that a lot of folks in the industry have already raised. I hope this will push CMS for more transparency, more data on the quality of these nursing homes. Right now, for example, they are considering adding COVID-19 vaccination rates of staff and patients to that rating. That is an excellent idea, given what we know about the vulnerability of that patient population. 

Overall, it has pushed patients and their families to consider that choice with wanting more information and better information. Hopefully that pressure from patients and their families will give us even more transparency than what we have today.

WellSky said when it acquired CarePort that it would invest significantly to expand CarePort’s capabilities. What changes do you expect to see?

Luckily when we went through this process of parting from Allscripts and choosing our next home, we had a choice, which is important. When we spoke with WellSky and we talked about our shared vision, I wanted to be very specific around what that meant, rather than amorphous corporate jargon about synergies. I was impressed with WellSky because they had been thoughtful about the process. Given the price that they paid, it makes sense that they were thoughtful, speaking in the realities of the world. 

Specifically, in terms of the benefits to our customers, there were probably three things that we looked at and valued. The first is, as we are seeing more of a shift towards home-based care, our clients are asking us to connect more and more with these home-based providers. WellSky is in one in four home health agencies in the US. Being able to add those agencies to our network, both as referral partners and to add visibility in terms of that ADT and deeper clinical data, was valuable out of the gate for our customers.

The second piece was that WellSky has a network that goes beyond home health and delivering medical services into the home. They have a huge network in the social determinants of health space. Again, as we are seeing more of a shift home, there are more concerns around how the patient is going to get their meal. How do we think about the non-medical parts of their care that we can support in their home? That was another piece that the WellSky network added for our customers.

The third piece was funding. The deal closed on December 31, 2020. We started the year with 200 people and we are already in the process of trying to hire 50 more people to our team.

You’ve said that you want CarePort to be a place where smart women want to work. How do you make that happen?

It all starts with the culture that you build. When I was in business school and in medical school — and I’m almost embarrassed to admit, even when I was taking classes on corporate culture and team dynamics — those soft classes almost felt less important in some ways than the finance and accounting classes. The hard business classes, if you will. I have to say that my biggest learning in these last eight or nine years since I founded CarePort is that it’s the opposite. Team building, figuring out how to manage, figuring out how to set up a positive culture where women are valued, where you enable everyone to speak up — that’s the hardest part about building a company.

At our scale, the lesson that I’ve learned is that it’s not even just about you and maybe the senior people in the team. You have to be hiring people at the manager level, at the director level, all down through the org, to make sure that those managers embody the competencies that they need to meet the roles and responsibility of that job, but the right culture and the right attitudes as well. That’s how you build a culture at scale. It’s not just from the leader, the CEO, the founder, the visionary. You have to staff in your company at all levels with people who want a positive working environment for women, who value the contributions of women, and who understand some of the complexities and challenges that women face. When you’re building a company and trying to recruit, all those things are difficult to prioritize. But really, that’s how you bake this into your DNA. You have to find people at all levels who embody that.

How did you protect that goal while being acquired twice?

You have to be thoughtful about why you’re doing the acquisition. To be fair, some companies just don’t have that choice. For us, luckily, we’ve always had optionality, because we’ve been doing well and we’ve had supportive backers, first from venture capital, then Allscripts. For me, when I evaluated an acquisition and whether we should do it versus do nothing and continue on our current path — because that was always an option that was available to us — there are two lenses that I always thought about. One is, do I see a tangible benefit to the customer? If the answer is no or it’s amorphous, then immediately we shut the conversation down. Because ultimately, if it’s not good for the customer, it’s not good for the business, end, period, stop.

But the second lens, once you get through that hurdle, is, is it good for the team? What is the feel of the culture of the other organization? What is their leadership like? What is that working environment? Is it a place where I could see my team thriving? Because as a founder, some of these people have been with me since the very, very beginning. They left higher-paying jobs with more security, they had families, and they came to a startup where there was none of those guarantees. I feel a tremendous responsibility to my team to make sure that they are taken care of and that my customers are taken care of. Not every company has this choice, but because I’m still here, because we’ve been doing well, because we have this choice, I wanted to optimize around both of those fronts and I was able to.

Do you have any final thoughts?

I’m excited about the future of acute and post-acute care. We have seen even more so than when we last talked, given the changes caused by COVID-19, the interdependency between acute and post-acute. In the next couple of years, I’m seeing payers become more involved in that relationship as well, as payers are trying to think about post-acute and think about how to work with post-acute. Those are some of the things that I’m excited about. Also, having patients who are more engaged, who have more data available to them. Those things will be important for patients who need post acute-care, a number that will only increase.

HIStalk Interviews Jon-Michial Carter, CEO, ChartSpan

Jon-Michial Carter is co-founder and CEO of ChartSpan of Greenville, SC.

Tell me about yourself and the company.

ChartSpan was founded in 2013. We were focused on driving patient engagement. Almost everything that happens in healthcare is built and designed for providers, with patients having the ultimate end experience. As chronic care management began to evolve in 2015, we realized — as a company that was very much focused on the patient experience — that this was an area that we would excel in. We started small. My brother and I and one other person founded the company. Within five years, we became the largest provider of chronic care management solutions in the country based on active monthly enrolled patient population.

I come from the technology world as an operator with deep experience in finance operations and sales. My brother, in contrast, was a 20-year practicing clinician. We made a great partnership in that he focused on the clinical side of things and I focused on the operational side of things. It has been a big reason that we have been successful.

How many providers, and what kinds, are offering CCM, and how many of them engage companies like yours for outside help?

Chronic care management is a Medicare program where providers are encouraged to telephonically and/or electronically engage with patients on a monthly basis. You engage with patients on the patient’s terms. You go to them when it’s convenient and you go to them when they’re at home.

The thought is that if a patient has two or more chronic conditions, and they are not yet high acuity, they are not a candidate for case management. We preventatively reach out to them every month. The data shows that we dramatically improve outcomes and reduce costs for those patients. You want to get those patients when they are low risk or rising risk, not when they become high utilizers of the system. That’s the entire focus of chronic care management. If you look at the CMS claims data, it is delivering extraordinary results.

In regards to what type of providers utilize the service, initially it was focused almost entirely on primary care, internal medicine, and geriatrics. That began to expand over the last couple of years. There are few specialty areas that we don’t have as customers providing chronic care management services to their patients.

How do practices market CCM to their patients to convince them to sign up and pay their part of the cost?

With COVID, a lot of Medicare patients are hesitant to go out in public, much less sit in a waiting room with other sick patients. We have seen a 30% increase in enrollments from our legacy customer patients. That’s encouraging, because the value for the patient is convenience. Our job as a turnkey service provider for our physicians and providers is not to practice medicine. That’s what they do. We act as an extension of the provider, dealing with the low-level care coordination activities that are so important to prevent the exacerbation of a patient’s chronic conditions.

For instance, we assist in making sure that they have appointments, that they have transportation to get to those appointments, and that they’re getting their medication refills. We assist them in having those medications delivered, or get transportation to get across town, to get to the pharmacy to get them. We make sure that we have the provider’s care instructions and that we understand exactly what the care goals are for that patient and are, reinforcing those and making sure that the provider’s instructions are being followed.

We have a bi-directional feed with our clients. We are extracting the CCDA out of the EHR. We are agnostic and work with every single EHR in the country. Then we push back our clinical data set wherever they want it in their EHR, whether that’s in a particular file or discretely in a patient record. On the billing side, we do the same thing. We push the billing to the billing department, to the practice management system, so that it’s easy to build those E&M encounters once we have had a compliant engagement with a patient on any particular month.

What issues do providers have when they do CCM on their own?

I have met with hundreds of practices and health systems that have attempted to do chronic care management on their own. I have never met one that was profitable. I have never met one that was able to achieve the volume of enrollment or revenue that they had hoped for. 

Here’s why. Everybody with a nurse and a spreadsheet thinks they can do chronic care management, and they are wrong. The clinical encounter is the most predictable part of CCM, but it’s not the hardest part. The hardest parts are all the operational complexities in the periphery. It includes enrollment. By the way, clinicians are traditionally terrible at enrollment. Compelling patients to be in the program. It’s solicitous in nature, and it’s almost uncomfortable. I know, because in the early days, we tried to have clinicians do enrollment and it was a miserable failure.

Enrollment is hard because 85% of your patients have a co-pay. You have to be articulate about defining what the value is in the program. You need data feeds that show you who the primary and secondary insurer are so you know what the co-pay and financial obligations are for the patient. That alone is one of the most difficult operational processes that you have to deliver with chronic care management.

But there’s many more. You are constantly doing data reconciliation. You have millions of patients churning into Medicare and millions churning out of Medicare every day. Churn is the name of the game. If you don’t know, from a data perspective and from a business process perspective, how to manage the daily churn that occurs in a Medicare program, you shouldn’t get into this business.

That stretches way beyond the clinical encounter. You’ll never get to the clinical encounter if you’re not doing your data reconciliation, churn management, patient marketing, enrollment, quality assurance, and billing support services. The clinical encounter is the depth of what most health systems think about when they think about chronic care management, and they are terrific at the clinical encounter. If that was all there was, then we would have a lot more people doing it and they would be a lot more successful. The problem is all the other operational components around the clinical encounter. Few people understand how to master that.

These Medicare patients with multiple chronic conditions probably have multiple active providers. Who decides which of them provide CCM services to that patients and what happens when the patient changes providers?

Being compliant requires that you consent the patient, and that must be documented. Once the patient has given consent to the provider, then that provider is the chronic care management provider of record. No other provider can come in unless the patient unenrolls and then gives consent to the next provider.

What are the best practices of performing CCM and the Annual Wellness Visit remotely?

From a CCM perspective, we do telephonic, and then we rolled out a multimodal approach last year, and it has been extremely successful. I would say 20% of our engagements on any given month are through SMS text messaging. There’s a fallacy in thinking that portals and apps are the way to go. Those are dead. Apps are dead. You don’t make patients go to your proprietary software to have an encounter. You go to where the patient is.

There are only two places that they ubiquitously are, on their phone and on their phone — telephonically on their phone and texting on their phone. We go to where the patient is. That’s why our engagement rates are off the charts. You don’t want to force them to have to open your app and enter their username and password. We have seen, through Meaningful Use, single-digit engagement rates for View, Download, and Transmit healthcare records. Our focus is doing what’s convenient for the patient.

That started telephonically, and now we’ve extended that to SMS text messaging. A patient has to opt in and give consent. We do it in a secure, encrypted, HIPAA-compliant way. But as Boomers age into Medicare, that youngest cohort in Medicare has a preference for texting versus telephonic engagement. It’s important that we go to where patients want us to go in regards to how they want to engage and communicate.

Does that dispel the notion that older patients are less interested than younger ones in using their phones to help manage their affairs, including healthcare?

Differentiate between phone and what we often think of as a computer. As we age, more and more of us are more comfortable with computers and using smartphones. We certainly see lower engagement levels around technology for older Americans. Data I saw last week shows that smartphone usage in 80-plus people is dramatically lower than 65-plus among ChartSpan’s cohort. It’s still a problem, and it’s a real problem, but it’s becoming less so over time as more and more people age into Medicare. Those people are coming from a world where they had to be able to manage digital tools like smartphones and computers.

You’re focused on a specific Medicare-paid service that CMS could change. How do you position the company accordingly?

We have been working hard on legislation that would remove the barrier of a co-pay. CMS released retrospective claims analysis for two years of CCM billing and it was eye-opening. It showed that for a patient who has been in the program for a year, taxpayers and Medicare save $74 per patient per month. After the reimbursement, they save 41 cents on the dollar, roughly $31 net. Keep this in perspective. There are 63 million Medicare and Medicare Advantage patients, and CMS says 68% are eligible for a CCM program. That’s 43 million patients. Take 43 million times $31 a month and you’ve just cut billions of dollars a year in spending that goes back to Medicare and taxpayers.

Congress is paying attention. There is a bill, H.R. 3436, that we have been working hard on over the last couple of years. We are trying to get this pushed through Congress and we think it has a decent chance this year. It would remove the co-pay. Why are we tripping over pennies to get the dollars? Why are we going to charge a patient $8 when taxpayers save $74? Let’s just save the $66 and move from hundreds of thousands of patients enrolled to millions, and let’s focus on improving at scale outcomes for patients and reducing costs.

We spent the first part of our company’s history focused on one thing, and that was chronic care management. We were deliberate in that. We said until we are truly the best in the world at what we do, we’re not going to expand into any other offering. I don’t know that you ever wake up and look in a mirror, and say, “I’m the best.” But we feel like, certainly from a size standpoint, that we are the largest, and we certainly think we’re the best.

We looked at other opportunities where we could grow the business. Our customers told us over and over that we should focus on Annual Wellness Visits. I didn’t understand that. An AWV seems so simple — a self-reported, 10-minute questionnaire by a patient. There’s no co-pay. How in the world are four out of five Medicare patients walking into the doctor’s office multiple times a year and never getting one of these done? If you look at any ACO, it’s one of their core operational components to do AWVs. It saves, on average, nearly 6% in cost on an annual basis for a typical Medicare patient.

What we figured out was that it had nothing to do with the questionnaire. It had to do with the fact that there was poor technology and poor processes around how AWVs are done. Again, according to claims data, only 19% of Medicare and Medicare Advantage patients got an AWV last year. When we studied that, we saw that there’s a 41% no-show rate for AWV appointments. Candidly, patients come to the doctor when they’re sick, not when they want to prevent something. So if you are scheduling preventative care appointments, you’re going to lose a ton of money in no-shows.

We designed a SaaS-based product that turns a sick visit into a well visit. When the patient comes to the doctor’s office, they’re predisposed while in the waiting room to fill out paperwork. Seize that moment. Give them a ChartSpan AWV. In 10 minutes, they will complete that AWV, which doesn’t interrupt the workflow of the provider and doesn’t put a burden on the practice. They hand it to the front desk. That patient report is either printed or emailed to the patient and the provider report is uploaded into the EHR.

What we also realized around AWVs is that the questionnaire is simple. The thing that’s largely ignored around AWVs is the upstream and downstream data component around that. When I say upstream, I mean that there’s not an AWV in the country that’s checking the HETS database in real time to even know if that patient is eligible. Furthermore, if you’re missing demographic data as so many patients are, there’s no query system that reconciles that missing data and prompts, in real time, the front desk to say, “Hey, we’re missing a Medicare ID,” or, “We’ve got a change of name.” Fix it and then hit the HETS database in real time so that you actually know if that patient is eligible and which AWV code they’re eligible for. We built all that.

On the downside, the real value of an AWV is the aggregate care gap identification data that comes from an AWV. Quality managers are having to figure out, how do I port that into my population health system? How do I make sense of this? We spent a lot of time investing and building the backend data that allows a quality manager to go in and say, “Of all the AWVs today, this week, this month, this year, where do I have care gaps for fall risk assessments?” or whatever the quality measure may be. That data then needs to become actionable at the patient level. We built that as well. It’s a really sophisticated AWV product and we are really proud of it. We don’t think there’s anybody in the marketplace who has anything like what we have.

HIStalk Interviews Kelly Feist, Managing Director, Ascom

Kelly Feist, MBA is managing director of Ascom Americas of Morrisville, NC.

Tell me about yourself and the company.

I started my career as a bedside clinician. I worked for 10 years at a couple of acute care hospitals in Florida in the respiratory care department, covering intensive care units, emergency departments, and neonatal ICUs. I have a strong appreciation for what a clinician experiences each day and their need for not just information, but information that is actionable and easily interpretable.

I joined Ascom on April 6, so my first day was after the pandemic started, which is an interesting way to start with a new company. I was drawn to the company because it is going through a transition and a transformation, moving from capital equipment to  focusing more on workflow, clinicians, and patients. Our healthcare information and communication technology helps clinicians deliver bedside care in an effective way, managing communications between clinicians and from patients to clinicians. We start at the bedside with the patient in the center with nurse call, and then move out to mobility devices. It’s an end-to-end, integrated workflow that becomes increasingly important as we find new ways to manage clinical care while trying to limit contact.

What are the challenges and benefits of collecting and presenting information from hospital monitors to clinicians on mobile devices?

It’s not just hospital monitors, but also ventilators and laboratory test results. A vast amount and a vast variation of information can be presented on mobile devices in the clinician’s hand. It’s not just the information, but the actionable information. We can deliver so much information when we digitize a workflow that was previously analog. We can put a mobile device in the hand of a nurse at the bedside that can receive alerts from all of these different devices — ventilators, patient monitors, lab systems, and so on. A lot of information can hit that handheld and overwhelm the nurse.

The challenge is to identify what information is truly actionable and how that information is escalated so that the nurse can respond in an efficient and informed way to solve the patient’s problem. You can’t overwhelm people with a lot of information and then expect them to decide what’s important and what can wait. The value that we deliver is helping them understand how they should be prioritizing that information so that care providers aren’t overwhelmed by a new workflow that now happens to be digitized. Just because we can digitize it doesn’t mean we should.

Is technology such as AI, which is a term I hesitate to use, improving the ability to automatically prioritize information instead of having each facility or each user set up rules?

I share your reluctance to use the term AI. It is overused, and applying it in a way that makes sense is easier said than done.

I think about whether a hospital already has rules and policies in place. For example, does the facility have a policy for early warning scoring, where they have determined the parameters that can help identify a patient who is at risk for deterioration over time and then raise a flag before they become symptomatic? If that protocol exists, we can program it into the software aspect of our solution. We will raise the flag and create and escalate the communication in an automated way for the care provider to ensure that the patient who is at risk is identified quickly.

Most people don’t realize that the first indicator is typically an increase in respiratory rate. If we see it increase, or see the lactic acid test results increasing, the software can raise the flag, create the communication to the care provider, and escalate it in an automated way. That pays dividends. Healthcare facilities want to spend their capital equipment dollars on something that delivers measurable ROI. That becomes important in making their clinicians more efficient, keeping their patients safe, and increasing their own capacity if they can release patients or discharge them sooner. It’s a lot to say that, but we have done studies that have shown that at the very least, a well-designed, well-executed protocol decreases unplanned ICU admissions, for example.

How much of the nurse’s work can now be performed untethered, working from a mobile device that they carry at all times instead of being tied to a nursing station, a wall-mounted computer, or a computer on wheels?

As we are working with customers who are deploying these solutions, we find that the idea of the nursing station is going away. The push is to move the nurses and the frontline care providers closer to the patient and away from a centralized nursing station. This is the first real change that mandates finding new and better ways to manage that workflow.

It’s easy to think that we can apply technology to a workflow and change behavior because the technology exists, but the hardest thing to do in a clinical environment is to change the behavior of the care providers. Behavior change is always the hardest thing to affect. But if we can take our technology and support existing behaviors and make them more efficient, then we all win. The patient wins, the care provider wins, and the company wins.

That’s what we are focused on. As care and nurses move away from centralized nursing stations to something that is more distributed, it becomes important to have a communication device that pushes alerts to your hand. It allows instant communication to the care provider who knows that there’s a problem. Typically there’s also a secondary escalation path, so if that person is busy and can’t leave what they are doing, they can press a button and move it on to the next person, who can then respond. This allows us to build in safety nets.

I don’t think it’s reasonable at this point to think that all clinical documentation that goes into an EHR, for example, will go through a mobile device. Anyone who tries to type emails on their IPhone or their Android device understands why that is a challenge. But we can support the use of the EHR. Our goal at Ascom is not to compete with EHRs that are in place, but rather to support workflows and behaviors that enable and facilitate better use of the EHR. If we can close some workflow gaps at the clinician level and get the data into the EHR for a continuous health record, that is important. If we support the implementation of the EHR and make it successful, we can affect real change in the clinical process, and ultimately the outcome of the patient.

How can technology replace the continuous communication that occurs at the nursing station?

The mobile device becomes important. How well does it integrate into the overall workflow? How easy is it for the staff to communicate to one another, either voice-to-voice or via secure text message, or to receive alerts? When we think through an alerting process, there’s alerting the primary caregiver. But if that primary caregiver can’t respond, there has to be a secondary alert target, and then even beyond secondary, what we would call a catch net solution. Making sure that there’s a Plan A, a Plan B, and a safety net becomes important, because that central station doesn’t always exist any more. And even if it does exist, it isn’t always staffed 24/7.

We have to make it possible for communication to happen in an expedited way that fits into the workflow and meets the needs of the clinician where the clinician is. We are accomplishing that with mobility solutions, the software that drives the mobility solutions, and even starting at the bedside with the nurse call system so that the patient can communicate their needs as well.

What are the best practices in using technology to enable patients to communicate directly with staff to improve satisfaction, but avoiding overwhelming the employees who have to respond?

A care environment typically has registered nurses who are responsible for a level of care, and then often healthcare technicians or licensed nurse practitioners. If we can segregate the requests that come from the patient — based on need, priority, and criticality — to the right provider of those services, then we can get a faster response to the patient.

Patient satisfaction is incredibly important to our care providers, to the facilities that they work for, and to us. If we can make it a little bit more streamlined so that when the patient has a request — it could be, “I need a glass of water” — there’s a way for that patient to communicate and it can go to the LPN. It can go to a targeted recipient that can provide that service without them taking up time of the nurse who might be working with another patient on something that is more critical. But if it’s a critical need, the communication goes to the nurse. We can filter where the request goes based on priority to make sure that the patient gets the response they need in a timely manner.

What are the company’s goals in healthcare over the next few years?

Healthcare is our biggest growth opportunity. For my region in the US and Canada, it’s where the majority of our revenue comes from. The pandemic has shown how impactful we can be to the healthcare community.

As an example, when I started, field hospitals were springing up all over the place, such as at the Javits Center in New York City and McCormick Place in Chicago. They needed to give all patients in beds access to nurse call functionality. We were tapped to provide a lot of the technology for those field hospitals, and it felt good to be able to serve the community in a way that had impact. A lot of the field hospitals didn’t get a lot of census, but the fact that we were able to meet the needs of the community when those needs occurred was important.

Workflows have changed because of the pandemic and we are trying to decrease contact where we can to keep both patients and staff members safe. Ascom can play a big role in that. Those workflow adaptations aren’t all going to go away when the pandemic is over. We have to keep innovating on how we make communications more streamlined, more effective, how we get them to the right person, and how we ensure that priority items are escalated appropriately. Those will remain important. With virtual visits and other changes, we will need to monitor patients at home effectively. Ascom can play a part in that realm as well.

Do you have any final thoughts?

The workflow changes that we are experiencing as a result of the pandemic aren’t going to go away. Keeping the patient and clinician provider at the center of what we do will make healthcare delivery more efficient, and that will make us successful as a company. Focus on the patient and the provider.

HIStalk Interviews Abhishek Begerhotta, CEO, 314e

Abhishek Begerhotta, MS, MBA is founder and CEO of 314e of Pleasanton, CA.

Tell me about yourself and the company.

I founded 314e in 2004. I used to work as a programmer on a project that IBM had undertaken to create a clinical information system for Kaiser Permanente. In around 2004, I think, Kaiser fired IBM and hired Epic. The rest is history. That’s when I founded 314e to provide services to Kaiser. Since then, we have worked with over 250 organizations across the healthcare value chain, including providers, payers, med tech, and life sciences companies. Our core areas of competence are EHR implementations, cloud, data engineering and analytics, interoperability, and automation. We take pride in delivering high quality at a reasonable price to our customers. 

How are hospitals complying with the requirement to send ADT messages to the patient’s other providers?

We are working with a few customers on this. They all seem to have different issues and challenges, but I am unfortunately not up to speed on all of the details. I know that there are newer healthcare communication platforms emerging that facilitate this. 314e’s Muspell XI tool can also send ADT notifications, and we are working with a customer to integrate our tooling into their enterprise service bus to deliver these notifications to the right providers.

Where do most health systems fall in your eight-level Healthcare Analytics Adoption Model, and how are they prioritizing their next steps?

We think that most are somewhere in the middle, Level 3-5. We certainly have customers that are at Level 7, and we have helped them get there. Most organizations we know struggle with managing complex ETLs and getting data to a warehouse. The processes are brittle and do not support any form of self service or business agility.

We are seeing a trend towards adoption of cloud analytics platforms like Databricks on Snowflake running on Azure / AWS. These systems give the basic infrastructure on top of which high quality BI, AI/ML workloads, etc. can be run. Our customers are tapping us to migrate from decades-old warehouses to such more modern data lake / warehouse environments to get to Level 6 and higher. In fact, we are helping several customers today in collating EMR, imaging, lab, registration, claims, patient satisfaction, and home health types of data into FHIR-based enterprise data lakes. This results in getting to Level 4-5 in under a year.

Will the move to virtual implementation and support services continue even after some degree of normal travel resumes?

The pandemic has really exposed a lot of inefficiencies and waste in the healthcare industry, and one of those is the cost of travel and lost productivity for implementation consulting.  With the shift to virtual, we’re adapting and becoming accustomed to doing things remotely, leveraging modern technologies like Teams and Zoom.  

There are certainly some things lost by not having those face-to-face interactions where you build and strengthen relationships and alignment between IT and operations. So I do believe that some key personnel will start traveling more frequently when normal travel resumes. But overall, my gut tells me this trend of virtual implementations will continue.  

Training and at-the-elbow support, specifically for new implementations, are two key areas that are presenting unique challenges for our clients to deliver virtually. I anticipate, at least for new implementations, that we will see those services resume to more in-person.  We have spent considerable investment developing solutions and a product for our clients to address ongoing new hire training and ongoing on-the-job performance support which can be delivered digitally anytime, anywhere and provides on-demand targeted training assistant embedded in the EHR workflow. That trend is moving to more virtual.

How much interest or potential are you seeing in robotic process automation?

RPA adoption has been turbocharged by the pandemic. Providers and payers have both realized that RPA can make the processes more efficient and reliable in addition to the cost savings it brings. A Gartner report published in the middle of 2020 said that around 5% of healthcare providers in the US have invested in RPA and that this number will reach around 50% in the next three years. However, almost all of our customers have started at least one pilot initiative around RPA in some way, shape, or form, and many have at least one proof-of-concept in place. Most of them don’t have in-house capability to deal with this and are working with partners like 314e. 

As a company, we are very bullish on automation, web automation as well as desktop app automation. We are building products to help customers deploy RPA to automate enterprise workflows. We believe that there is a need for an RPA framework which can allow healthcare providers to quickly and easily deploy an army of bots for different problems and design an orchestration system to manage these bots. We are piloting our bot orchestration system with a customer today. 

How will payer-to-payer data exchange improve member experience?

CMS mandated the payer-to-payer data exchange to prevent fragmented member data from getting stuck in silos with different payers. Members can now have one unified record of all their health data, including claims data. This allows for a true continuum of care, not just across providers, but also across payers as the member switches jobs and possibly moves from one payer to the other. Payers need to use USCDI for this exchange. 314e has invested heavily in FHIR to help payers power such an exchange. 

What 3-5 year goals do you have for the company?

At 314e, we are playing the long game; the infinite game. We started out as a few people helping a large IDN with data conversion. Then we got into staff augmentation on Epic implementations. But today we are true technology partners to customers across the healthcare continuum. Our goal is to become the go-to technology provider of services for cloud, analytics, integration, innovation, and automation for healthcare.

We want to do this by IP-led service delivery and products. We already have multiple products in the market, including one that we call Speki, which means “wisdom” in Old Norse. Speki is a content, help, video delivery platform with a SMART on FHIR launch. It is currently on the Epic App Orchard. We can take instructor-led EHR training, convert it into byte-sized chunks, and make that searchable and viewable from within the EHR.

Similarly we have a FHIR-based enterprise data lake product that we call Muspell. It supports archival and clinical data repository use cases and can be a data aggregation platform used by providers and payers. We run this on top of Databricks and it is available on both AWS and Azure. We have dozens more product innovations that we want to bring to market in the next 3-5 years.

HIStalk Interviews Erik Littlejohn, CEO, CloudWave

Erik Littlejohn is president and CEO of CloudWave of Marlborough, MA.

Tell me about yourself and the company.

I joined CloudWave in 2013 out of a desire to be part of a team that served a terrific market, had great potential, and allowed me to continue my career in healthcare IT. One of the things that attracted me to CloudWave is that most of the people there had devoted their careers in and around various aspects of healthcare. 

I was fortunate to join it at a pivotal point in its transformation. I initially led our technology services organization that focused on the resale of on-premise technology solutions, storage servers, et cetera. I got to interact with a ton of customers and serve a ton of customers. Then over the next eight years, we continued our transformation from being a legacy reseller of those solutions to a multi-cloud services, edge, private public cloud that solved numerous challenges faced by hospitals. We are building and continuing to build something special, and we cherish the relationships that we have had with customers going back many, many years.

What does the mix of on-premises infrastructure and cloud computing look like for the typical hospital, and how is that changing?

When I joined the company in 2013, 70% of our proposals were on-prem integration types of deals and 30% were cloud-based, whether that was full hosting or disaster recovery. As we sit here today eight or so years later, it has flipped and completely inverted. I would say that 65 to 70% of our proposals and solutions are cloud-based and the remainder are on-prem, or what we now call edge solutions.

Cerner was becoming more active in hosting its own systems back then as I recall, while Epic and Meditech weren’t doing much of that. What is different now?

Cerner continues with its model and there are no on-prem Cerner solutions. All of that is hosted, and they have been successful at doing that. Epic and Meditech have been similar, in that organizations like CloudWave have provided private cloud hosting operations or solutions. Meditech has certified a number of providers like ourselves to be able to do those, and we go through certifications or testing on an annual or biannual basis. Like everyone else, Meditech has wanted to associate themselves with a public cloud offering, and about a year and a half ago, they launched a partnership with Google. Cerner has launched a partnership with AWS and Epic has certified its platform to run on Azure or AWS as well. Everyone made their claim to a partnership. We are doing the same things and trying to evolve our solutions to be not only private cloud, but to take advantage of public clouds and their evolution.

What are the practical results of hospitals moving some of their data center operations to cloud providers?

Some of it becomes a preference based on financial models, whether it helps them to have an operational expense versus a capital expense, for example. A lot of organizations prefer CapEx, so the cloud may not fit that model very well. However, clouds, public or private, offer a lot of other benefits. Think about hospitals trying to maintain talent and the number of skills that you need for various software vendors, and keeping abreast of those certifications. Complex security challenges are daunting for organizations today, and it has been tough to keep up, particularly if you are a community hospital, with all the ransomware threats coming out of any number of countries these days. Then maintaining all of that talent over time. Healthcare certainly has been slow to adopt cloud solutions over the years, but they are becoming comfortable that that cloud can help them solve some of those challenges.

How has cloud deployment helped hospitals prevent ransomware attacks and recover from them?

First and foremost, it’s ensuring that you have the basics done of clean backups, that you have recover points that you can go to when – not if – someone is impacted by a ransomware or security event. Ensuring that there are multiple copies and multiple restore points and options you can go to so that you know you have a safe recovery point, and trusting in an air gap type of solution. We have multiple sets of data or backups available for customers, and that gets pretty expensive and complex for any organization to manage by themselves. That’s another reason that working with cloud providers makes a lot of sense for hospitals.

Why do attempts to restore from backups fail so often?

We test ours on an annual basis for our customers. That in and of itself is a huge difference. You think your backups are fine and you see that all the saves were occurring, but until you actually restore that and try to run the system, you just don’t know what you have or you don’t have. We feel like doing that annual test is critically important, and it’s a big reason that a lot of customers want to do that and choose a recovery service or a backup service with us. Otherwise, they probably wouldn’t do it on their own.

It becomes a good tool for the organization to rally around. They have this recovery test over the span of a week, they get clinicians involved, and they get people to pressure test it and figure out where the kinks might reside or find issues that need to be fixed. Figuring out what didn’t go well is as important as anything else in a test so that we can make sure they have a clean, restorable backup that they can rely upon.

What do hospitals typically need to do to prepare for moving to the cloud?

The funny thing about being a cloud service provider is that your service is only as good as the end user’s perception. Looking at connectivity and service providers in the local area is important, ensuring that you have multiple paths and redundancy in case a provider has an outage, that you have the capability to fail over and have adequate bandwidth when there’s some sort of outage with Verizon or AT&T, et cetera. First and foremost, you need to make sure that’s solid and that you have redundancy. You also need to make you have adequate Active Directory permissions and user access.

It isn’t just flipping a switch and saying, “I’m going to go into the cloud tomorrow.” We spend one to two weeks assessing the readiness of our customers and remediating any issues that may exist. That holds true with any cloud service provider. You need to be thoughtful about assessing anything in the environment that may impact an end user’s ability to use the system successfully, and make sure it’s not going to be slow, that it doesn’t time out, or that you don’t encounter authentication type of issues, because that creates a downstream headache for everyone.

How do you see the company’s business and strategy changing with its recent acquisition by a private equity firm?

We are excited about the Abry Partners investment. They have a great reputation and a ton of experience in our industry. We felt like they would help position us for future growth and enhance our capabilities, grow our team, and provide meaningful strategic input or guidance. Just as importantly, we just liked their team. There is a sense of familiarity, a lack of ego, and a near-perfect alignment about the potential of our business. We couldn’t ask for a better partner, and we know that they are willing and able to invest in capabilities that we need going forward, whether that’s acquisitions or building our organic capabilities.

What were the most useful lessons you learned from being a West Point graduate and an Army officer?

One of the things that I always talk about with the team is explaining why. That may seem counterintuitive if you’re thinking about the military and you think of people just being told to take the hill, salute smartly, and go do it. But in the military, we always concerned ourselves with the commander’s intent. I had to understand what was going on to the left and the right of me, why I needed to take that hill, and how that fed it into a larger objective. It is important as leaders to always provide that context and the “why” to our teams and the people we work with. Because if you just ask a question without context, they may not give you the right answer, or they may not meet the ultimate objective that you are trying to get to.

What will the company’s emphasis be over the next few years?

We will expand our use and footprint of public cloud and make that more accessible and user friendly to our end customers. That’s an important part of our growth in the next three to five years. We will continue to diversify our capabilities and provide more services than we do today beyond hosting and recovery and backup, providing other things like service desk and security services and expanding those. We will also diversify our customer mix. We have been pretty focused on the Meditech space up to this point, or hospitals running Meditech, but we think that nearly all of our solutions translate nicely to hospitals running other EHRs. We are having some success in Cerner hospitals and Epic hospitals, and we are anxious to do that and to serve a wider mix of customers.

Do you have any final thoughts?

CloudWave will continue to be a customer-first business. Our relationships with our customers have always been at the center of what we do, and we are going to continue investing and expanding in those relationships in various ways. We can be a great partner with customers that are looking to transform their operations through the adoption of cloud. We see the whole industry being at an inflection point and more aggressively adopting cloud, and we are in a great position to do that based on our experience. We look forward to helping customers in that journey.

HIStalk Interviews Scott Finfer, CEO, Emerge

Scott Finfer is co-founder, CEO, and board chair of Emerge of Dallas, TX.

Tell me about yourself and the company.

I’m CEO of Emerge. We offer a solution set that can overlay on top of EHRs. The strength of our company is our people, a unique group that has come together.

How common is it for EHRs to offer a search function and how is it used?

Search can mean different things to different people. In the world of Emerge, when we talk about search and when we talk about what our mission is, it is searching not only the data that exists inside of the EHR that is discrete and accessible, but also information that isn’t necessarily searchable by the EHR unless they are using optical character recognition and natural language processing to use scanned and free text information.

But more importantly, when we talk about search, we stay patient centric. If I search for information about a patient and I’m at an ambulatory facility, in an ideal world, I should be able to have their records available to me if I need to treat that patient inside of the acute world. We’ve made our life’s mission to figure out how that search is not just about searching in records that exist — that’s the easy part — but searching for all the possibilities of where we can bring this information together on a master patient index to have one patient file that can theoretically travel with the patient wherever they go.

Does it make clinicians more efficient or allow them to find the most important information more easily?

I got stuck in healthcare. I’ll be honest about that. I didn’t realize how incredibly difficult the space was. I came out of IT services. Before that, I was doing real estate. I’ve made tons of money doing everything I’ve ever done, but I’ve spent tons of money over the past 10 years to build this business up, because healthcare is way harder than we expected.

But the good thing is that we now have the ability to understand what the problems are. We can document and have engineering problems versus, wow, it’s just not going to work. That’s a big difference. You can say, is it solvable? Well, maybe. Everything is potentially solvable. But what’s better than solvable is that it’s an engineering problem. If we do this, this and this, this allows for this to work.

That’s where we are at this stage of development. The people in the country now – patients, administrators, forward thinkers, caregivers, providers –everybody keeps struggling with these friction points that exist that are self-made. One of the big friction points is that, what is the center of importance in healthcare? I would argue with you that it is often missed, because providers are the center of healthcare. The patient is the center of healthcare. This isn’t against any particular EHR, it’s against every EHR that provides acute services at a bare minimum. Why are the systems developed around hospital beds as opposed to patients? The whole thing is designed for something different than staying focused to patient care.

We have the problem now to fix all these silos. Then it’s compounded by the fact that,  who is the best source? Is it one source or multiple sources? All these things are playing friction. The one thing that has never been delivered, regardless of what belief system you’re of — and I’m a no belief system here, I’m neutral, I just want to help healthcare — is that getting my record in and out and moved around and shared has been a disaster.

One of the reasons is because, most of the time, that’s a manual exercise that happens in the back office. People don’t think about this or don’t know this, but when there’s an official records request, it’s a money-losing proposition for the facility to have to go back through and figure out what the record is. Our technology, because it breaks everything down and starts with the patient at the center, says, I always have to keep it. Wherever it came from, I should break it down and bring it to the patient. That should always be the focus of whatever I’m doing for my flows of information.

When we encounter a situation where a health system is on multiple EHRs, we can come in and they don’t have to make any more investments. We can overlay on top of those systems and not only make them communicate with each other, but we can start to automate and provide smart services. Like, push a button and here’s your health record, because we can define what it is. I can get it for you. That’s what we have with ChartGo. With the push of a button, you’ve got the health record.

If it’s that easy to grab control of the health record with so much more granularity, now we can go to the big health system. We’re talking about big health system in California, and they want Northern California and Southern California to communicate with each other. But even more important than that, they want their patients, when they are traveling on holiday, to have easy access to their records and to share if needed wherever they are. That’s now possible because it’s being patient centric.

Is it difficult to access the information so you can create the overlay?

No. The most difficult thing in working with these facilities is the facilities themselves wanting to work with you. There’s this fear with some organizations about what is going on with the cloud. As you look at a lot of healthcare systems, it’s heavy steel. Man, it’s big money up front. For me, that’s fine. You don’t even have to change what you’re doing, but for pennies on the dollar, I can automatically make you 100% digital in the cloud. Your data, your control. Tell me where you want me to send it. That has never happened before. It has always been under the control of whoever sold you the operating system. We can help change operating systems, make them work better.

We’ve got a wonderful partnership going with a couple of EHRs right now, Athenahealth and Allscripts. Their senior leadership says out loud – which I’ve never heard someone say — we’re not the only thing. We’re part of the infrastructure. We’re part of the ecosystem. I said to myself, wow, they get it. There’s not going to be one — it’s not going to work. It’s got to be able to work together. Part of working together is knowing that some people might be great EHRs and some people might be great this or great that, but at the end of the day, what is needed is glue to make them work nicely together. Forward-thinking people, and there’s a lot of them, recognize that this is an ecosystem play. That’s where we are headed.

We know how to operate in any ecosystem because we speak all languages. Doesn’t matter which EHR, doesn’t matter the versioning, doesn’t matter the age of the technology. Our guys are utilizing state of the art technology and there’s no lift on the back end. I come to you and I say, let me solve your problem for you. The facility says, what’s it going to cost? Nothing. OK, and what kind of resources do I need to provide for you to do that? None. They look at it and they go, it’s not possible.

After surviving being told that for 10 years, we now have successful investment bank software company. The most important part about it is that we did it with our own money, and now it’s making enough money to stand on its own two feet with no venture capital in the deal. We did it to solve healthcare problem because my co-founder, who is a doctor – cardiologist William C. Daniel, MD, MBA — is a humble enough guy to understand that when you’re treating patients as a cardiologist, there’s plumbers and there’s electricians. I love this guy. I’ve known him since I’m 13 years old. I wouldn’t have gotten into this business if it wasn’t for him.

What he said to me was, I’m killing people. I said, what? I’ve never heard a doctor say that before to me. He said, I’m 100% killing people. I know I am. I just can’t prove it. I’m seeing people in my office who are coming to see me because I’m a plumber. I don’t know electricity all the way through the detail. There’s stuff going on that if the EHR record was scrubbed, I would know that this guy needs to see an electrician, and I would get them to the electrician. That’s how this whole idea came up.

ONC pushed EHR vendors years ago to make it easier for users to export patient data from one EHR that could be imported into a different EHR, making switching easier. Has that gotten any better?

There’s no lift. Zero. We literally have converted over 100 different brands of EHR into the systems of our trade partners. They are left with non-usable data most of the time coming out of whatever EHR they’re coming from. Athenahealth is a partner of ours and one of our prime relationships. When Athena signs up a new customer, Athena brings us to meet the customer, because the customer can literally have everything waiting for them inside of Athena. They have access to not only to their old data, they have access to 300% more of their old data. 

But that’s not even the big kicker.They didn’t have to do anything. They turn on Athena’s state of the art system in the cloud, and it’s set up and ready to run. All of a sudden, both the old information and the new information through Athena are able to merge together as they see new patients through Emerge on a go-forward basis. They are always getting the full context view. If we need to add on other feeds from other EHRs, HIE, or API to allow somebody else to pump in a third-party data from a payer, all those things are now possible. That’s what we are building with Allscripts and Athena.

What does it take to sign new partners?

I don’t think you have to sign on new partners. I had a wonderful client and mentor in Oklahoma named John Harvey. He told me that he took a chance on us. He brought us up to the Oklahoma Heart Hospital early on, even before we really had a product. That’s the truth. We thought we had a product, but we didn’t realize what a problem there was in the space. John brought us up there and we were doing great stuff. We were going after every EHR back then. We were going to try and integrate with everybody. 

John said, if you boil the ocean, you’re going to die. You had better pick one and try and make it work. Then if you can make it work in one, you can make it work in all of them. 

That’s exactly what we did. Now we are in four of them — Epic, Cerner, Allscripts, and Athena. When I say having to get a partnership, I’d love to do a partnership with Epic if they want to do one with me. I can save millions of dollars in conversions for anybody switching to Epic. To bring their database from their old system to the new system will cost them $25,000. I mean, this is the digital age, so I have a digital solution. A lot of people are beginning to embrace it, and things are going to change rapidly. But the most important thing is that it works, it’s patient centric, and it’s following how medicine is supposed to work.

What is the direction of the company going forward?

We see ourselves following the same footprint that we started 10 years ago. A lot of companies set out to solve problems, and then they bring the solution to market. They say to the doctors, nurses, providers, staff, administrators, or the quality people –if you would only use my tool how I designed it, it would work for you. There’s a problem with using my tool as I designed it to work for you, and that is workflow. Part of our strategy has always been to make sure that we are directly in the workflow, but not in the way.

We have done that now with over 100 installs. You could literally take our install list and pick anybody on it and ask for a referral and they’ll give you one, a good one. Everybody’s happy. We have this massive retention rate because we’re in the workflow. That is key for where I see ourselves as we move forward.

Our roadmap for the past 10 years was written by my customers. With my subscription model, somebody says to me, I wish I could track proteins on these pregnant women that are coming in from all these facilities. We say, we can help you with that, and we do that for them. Then we turn around to any other OB-GYN who has a subscription with us and we give them that same functionality if they want it. Our subscription gets stronger and stronger, and what we are doing gets stronger and stronger.

We are much much more than search at this point. That’s a small underpinning of what the company is really doing. One of our strengths is the downtime viewer. If your EHR goes down, you can log in through our portal and have a digital version of everything available through our search tools, to be able to search the record while you’re in downtime. We have population health tools that don’t require an SQL search. You don’t need to spend millions of dollars to have a consultant come do this. Tell us what you want. I want to find all the patients that have not had a colonoscopy in the past 10 years and that do not have an appointment scheduled. Give me that list. Oh my God, 10,000 people that should be getting this procedure done. That’s 10,000 times whatever the cost of a colonoscopy is, $1,000, massive revenue from the existing population. And if they don’t do that, the cost of care is going to go up.

We are getting proactive, making sure that we’re hitting large target parts of the marketplace all at the same time. We have a way to find them. More importantly, we have a reverse delivery message available. If you miss something on coding and the only place where it’s appropriate to code like that is between the patient and the doctor at the point of care, it has to be done at that point. I’m inside the EHR and I have dashboards to use it in their workflow. If there is something that that doctor needs to code, adjust, or to change because the customer can now be paid for the work that the doctor’s already done, it’s a very efficient way to put it in the workflow. It can even get caught before the doctor does it, because we’re using our automated tools for the chart prepping process. We can chart for up an entire facility with a push of a button.

I don’t know exactly where it will be 10 years from now, but we’re going to do the same thing that we’re doing, which is, show us the problem, give us your requirements, let us solve it, and help us make our subscription stronger with each new member.

HIStalk Interviews Kevin de la Roza, MD, Anesthesiologist, Arnold Palmer Hospital for Children

Kevin de la Roza, MD is a pediatric cardiac anesthesiologist at The Heart Center at Orlando Health Arnold Palmer Hospital for Children, assistant professor of anesthesiology at the University of Central Florida College of Medicine, and SVP/GM of Vocera’s Ease business unit.

Tell me about yourself and your work.

I’m a pediatric cardiac anesthesiologist at Arnold Palmer Hospital for Children in Orlando, Florida. I take care of babies and children that have congenital heart defects when they have heart surgery and any other type of surgery.

How is the Ease app that you developed being used?

It has been quite a remarkable journey for us. We created this from the need that, as anesthesiologists, we are the last person to take family members to surgery and away from their loved ones. We thought it was pretty barbaric the way that families are being ignored, whether they were just getting a phone call once in a while or maybe never when their kids or their adult loved ones were off to surgery, or had a board that they were looking at that didn’t tell any information.

The app is used universally in any location. We made it nimble and user-friendly for not only the families, but also the nurses. It fits in well with their clinical workflow and with the physician’s workflow. It has become an efficient way for us to communicate. You could be communicating with a loved one while I’m talking to you right now — via text or even a photo or a video or something like that — and it wouldn’t disrupt your workflow. We wanted to bring in the modern way of communicating from our world into a HIPAA compliant and secure way to do it in healthcare.

You see that moment on TV or in movies where the surgeon dramatically enters the waiting room full of anxious family members. How is the mindset different for the surgical team when they have the ability, and maybe then the responsibility, to provide regular updates to family members who may not be in the same city or even the same country?

We are all so connected now, whether it’s online or otherwise, that we are ready for instant information and instant gratification with knowing what is happening with our loved ones. We can track our package from Amazon, so why can’t we track our loved one’s progress and know what’s going on? 

When you talk about the care team, there are two aspects. There’s the surgeon and anesthesiologists, then the nurses. Vocera Ease is the modern way of communicating. It is a non-disruptive and it doesn’t bother their workflow. A nurse is used to taking essentially a snapshot or a barcode on the patient’s wristband and scanning it and getting a medication. We created the app to be the same way, so that whenever the patient or the nurse wants to send a communication, they scan a wristband and send off the message. That could be from the surgery or medical floor, because the program is now in the ICUs, medical floors, radiology, the cath lab, and obviously surgery, where it was born.

It’s a non-disruptive way for the nurses to communicate. Previously, if they were able, they would have to stop what they were doing, get on a phone, and call the families. Sometimes they answer, sometimes they don’t. Then have a two-way conversation, which can be disruptive. The surgeon might go out to the waiting room and the families aren’t even there.

You alluded to the fact that we have so many loved ones in other states and other locations who can’t be there. The great thing about Vocera Ease is that it sends one-way messages from the clinicians out to the family members that give them a step-by-step story of what happened, whether it’s on the floor, in the ICU, overnight, or in surgery. It is a remarkable way to communicate and increases efficiency. When those surgeons go out to the waiting room, the families already know what happened, so it’s a short, efficient conversation. The surgeon can move on to whatever is next in their busy schedule.

Do the messages go beyond simply “we’re starting anesthesia” or “we have made the first incision?” I can see where it might be dangerous to convey conclusions early in a procedure.

We reflect milestones. Let’s say your wife or your loved one needs surgery. First, there’s the emotional impact of, “Oh my gosh, they’re going to have this.” Then the surgeon will tell you in their office or wherever preoperatively, “These are the steps of what’s going to happen as it happens.” The day of surgery, you meet your anesthesiologist, who tells you, “This is what I’m going to do. I’m going to take you there. I’m going to give you some IV medicine and get you off to sleep,” et cetera. The patient and family members have a vague idea of what there is, and that vague idea can become fearful when you don’t understand, you don’t see what’s happening, and you don’t have that checklist of what’s happening.

Ease allows them to receive these one-way communications, such as “The patient is in the operating room” with maybe a little picture with a thumbs-up before they fall asleep. Then we will send them, “The patient is safely under anesthesia. Bill is now prepped and ready for surgery and Dr. So-and-So is about to walk in.” When Dr. So-and-So is scrubbed and over the drapes, we might take a little picture of him about ready to start. Then if it’s an orthopedic procedure, we might take a picture of an x-ray and say, “This is the fractured hip. This is what’s going to be repaired.” Then we can show after the fact that the implant is in place and the repair is in place. They have a vivid understanding of what’s happening as it’s happening.

Does Ease offer advantages over consumer video tools such as FaceTime to help families communicate with their loved one who they can’t visit because of COVID precautions?

Ease is literally created for something like what the pandemic has brought about, which is communication with people who are unable to be in the hospital. The operating room or the ICU are isolated areas don’t offer much access and don’t have a lot of information coming out of them. Now the entire hospital has become like those areas with COVID and visitor access restrictions. We have put Ease in these locations and added — beyond one-way communication via text, pictures, and videos — a FaceTime or video chat feature, where there can be two-way interaction.

Ease is HIPAA compliant and HITRUST certified. We set the standard for what security should be in this kind of communication, and we were the first to be able to do it. We are proud of what we were and how we could position our solution to help families out during this time of crisis. Out of necessity, hospitals started using Zoom, WhatsApp, and all these non-secure ways of messaging that they never would have done in an era outside of the pandemic. With Ease, they can do that safely and securely.

What IT technologies do you find most impactful or useful to your practice?

It depends on the problem that you are trying to solve. When it comes to communication, which is what we were focused on, anesthesiologists are in the perfect position to solve this communication issue from the operating room. I have to balance the patient’s safety, making sure that the environment for the surgeon is correct for them. I even talk to the nurses a lot to communicate how we send the family about this, that, or the other to let them know what’s going on. It’s quarterbacking everything to give the surgeon the right environment so that they can operate and do what they need to do. In that milieu, I think it was perfect for us to — my partner and I, Dr. Hamish Munro — to come up with the Ease solution for solving the communication problem and using healthcare IT in that way.

We have many health IT initiatives that we are using now in the operating room, whether they be just simple things like timeouts and keeping track of things. The EMR has become such a useful tool to help us with that. But this one problem with communication wasn’t solved until we brought our solution on board.

You created a health IT product and company and then successfully sold them. Will you get involved in other health IT projects?

I would love to be involved in something like that. We created a team. My partner Dr. Munro and I came up with the idea together. Then my brother Patrick became the CEO of our company. He has an MBA, a background in IT, and was an administrator at a hospital before that. These talents came together. We created a team that can foster new ideas. 

With my background in medicine, that would be an amazing thing to see. I don’t have any idea just yet, but I love thinking about different solutions we can find, thinking about problems with the environmental impact of hospitals and how we can help that. That’s where my brain is going, but we’ll see where it goes. It’s an exciting time to help find solutions to problems that have been around for a long time, or that are just starting to come to the surface.

Are you still involved with the product under Vocera?

Yes. I’m a clinical consultant for them and I help them out with anything that they need with regards to the platform.

Do you have any final thoughts?

In the journey we’ve had with what is now Vocera Ease, from eight years ago to today, it was about finding a strong problem and then putting the components together to find a solution for it. One-way communication via text, video, and pictures is the perfect way to communicate outside of healthcare because it’s non-disruptive and gets things out there, so how do we go about this? Let’s go read about HIPAA. Let’s go read about HITRUST. How do we create apps? Everybody downloads apps, everybody knows how to text.

From there, you start creating the solution to the problem, as opposed to creating the solution and then trying to find a problem to fix. It was created from a place of empathy, from a place of need. We saw these poor family members struggling when they weren’t with their kids who were in the NICU for a long time or they were in surgery. It’s important to find that strong problem and then hopefully an elegant solution to fix that problem.

HIStalk Interviews Marilee Benson, President, Zen Healthcare IT

Marilee Benson, MBA is president of Zen Healthcare IT of Costa Mesa, CA.

Tell me about yourself and the company.

My husband Jim and I founded Zen after spending 25 years in healthcare IT. Our goal from that experience was to simplify interoperability, because we had learned how difficult it can be. Zen is our second company in healthcare IT. We sold the first one to WebMD in 1999. We’re one of those rare couples who love to work together and we thrive doing it. A lot of people think we’re crazy, but we love it.

The best part about Zen is that we’re made up of some of the best and brightest people who work in healthcare interoperability. We have a good mix of more experienced folks who have gray hair and the younger up-and-comers. That mix of experience and innovative new ideas is important when working on the kinds of problems that we work on every day.They are smart and dedicated, and we are laser focused on giving our clients the best possible experience. You will frequently hear our clients say that we are their favorite vendor to work with, and for us, that’s one of the most important aspects of what we do. We don’t take that for granted and we work hard to make that a reality.

What kinds of interoperability projects are customers working on?

We’ve certainly seen in the last year or so a big increase in the National Trusted Exchange-type implementations, such as IHE exchange and federated query and response. We’ve also seen an increase in FHIR-related projects, although typically we’re translating FHIR to the older standards. We may do a FHIR to IHE translation, or FHIR to proprietary API.

I’m excited about where we’re headed with FHIR and more API-based exchange, but we might also pick up a flat file and turn that into HL7. That represents where we are with interoperability today – it’s just extraordinarily complex. We have new emerging standards, but the old standards don’t die. That’s our challenge.

What impact are you seeing from ONC and the Cures act?

That will drive better adoption of API-based exchange, but we will need middleware tools that help bridge the gap from where we are today to where we are trying to go. Beyond the technical side, ONC is focused on information blocking, and its rulemaking process is helping push the business side, which is often the bigger problem. We can come up with technical solutions, but we need to have people on both sides of the transaction who are willing to share that data.

The other area is patient access. That has tremendous potential, but there’s been a lot of fear, uncertainty, and doubt for healthcare organizations to open up for better patient access to data. 

I’m excited about the business drivers that hopefully will once and for all ensure that sharing data is the standard way that healthcare is delivered, as opposed to that project that everyone’s always trying to work on, but never quite gets there.

What happened to the debate a couple of years ago about how vendors will approve who can connect to their systems via APIs, who owns the data, and who makes money from its exchange?

The information blocking rules are helping us get over that problem. I agree with you 100% that it has been a huge problem. It takes time to change people’s minds. But if you aren’t engaging in API exchange of information and opening up, both at a vendor level as well as in healthcare organization level, you’re going to have some explaining to do. You will need to have good reasons why you’re not doing it. That will apply a lot of pressure.

The other thing that will help is the tension that we have between the HIPAA minimum necessary standard versus information blocking. We are starting to get some direction from ONC around not letting minimum necessary be the reason that people aren’t exchanging data and clarifying some of those rules to address some of the legal concerns.

What unusual examples of interoperability have you seen?

We absolutely get to work on some pretty creative projects. Some of those things might include just moving data around within an individual organization’s suite of applications. We often think of data leaving the four walls and going over to another stakeholder. But often organizations are having trouble even moving data around within their own systems to leverage the data they are collecting to create a positive impact on patient outcomes. For example, you might pull data out of an EHR and several other systems and create a dashboard for certain types of patients, such as chronically ill patients. Those are fun projects to work on.

We also do a lot of work supporting health information exchanges across the country, and we’ve seen a lot of opportunity for health information exchanges to make a difference. For example, in the time of COVID, you can leverage the fact that you’ve got a data aggregator regionally that can help providers more quickly see whether, for example, a COVID test has been ordered and what the result was. That will obviously be extended to understanding the vaccine administration process and how we’re doing as a population. So the diversity of use cases for health information exchange is extraordinary.

We also have many great analytics vendors and analytics tools, but many of them still struggle with getting the data. So a lot of our work is in that area, helping get data into a format so that the analytics vendors can take that in and use that data for improved population health.

One theory of why Haven shut down was that it was starved of data by health systems that saw the company and its owners as adversaries. Are companies from outside of health IT surprised that they can’t get data that they thought would be readily available?

Haven was on my list of least-surprising news. I use HIStalk as my primary source of news, and when I saw your headline, I said, OK, that’s not a surprise. The problem is multifaceted. There’s the problem of the sharing of the data, and hopefully some of the new rules will help with that. But then there’s also the quality of the data. Even if you can get the data, there is a tremendous amount of work to be done to be able to leverage that data effectively from an analytics and population health point of view. Some of been around for a long time and we as an industry must do better at fixing them.

That includes patient identity and provider identity. Those are key pieces of information in a healthcare message, yet we struggle as an industry to manage them, using expensive tools that have a lot of management and maintenance. The industry is talking about these problems, but we still have a lot of work to do to fix them.

Does bringing in someone else’s data involve constant monitoring for inconsistent editing and storing of what seem like straightforward elements, such as blood pressure?

It has gotten better, but we still have a lot of work to do. ONC recently announced an effort around things like address normalization, which is great, but it sets you back on your heels to realize we’re talking about something as fundamental as that. Some of the clinical data normalization has gotten better with the evolution of the standards. FHIR in particular is doing a good job of being more specific in terms of the sharing of targeted clinical data.

How has the pandemic changed interoperability demand?

The two big things that we saw happening in the spring of last year were public health reporting, particularly with lab results, and telehealth. Telehealth was a big growth area for us last year.

I was a bit surprised that we had as much work to do in the public health side as we did. You might assume that we have public health registries, so data must be flowing, but in reality, there was a lot of work that had to be done. Many of the health information exchanges across the country were helping scale lab reporting, particularly to the public health agencies.

Integrating telehealth with hospital systems and provider EMR systems was a big area. I’m hopeful that telehealth is an area that we’ve proven has a has a bigger role to play in future healthcare delivery in the future and it isn’t just a blip. From an access to care perspective, telehealth has an important role to play.

Tracking pandemic-related hospital status, cases, deaths, and vaccination status is being done in some cases with primitive technology such as emailed worksheets and probably even fax machines. Are you finding that you have electronic provider data that those entities need that they can’t process electronically?

That is absolutely a problem. We do more work at the state level than the federal level, but it was surprising that even in states like California we had problems with the lab registry. Now we’re having trouble with the immunization side, where the right systems are not in place. This is an absolutely critical area that we have to invest in over the next several years. We simply cannot afford to not have that public health reporting infrastructure be modern and ready to tackle the next healthcare crisis that comes along.

Is it easier now that hospitals are using a reduced number of EHRs and other systems?

We still have a lot of ambulatory vendors even with consolidation. I’ve seen that vendor landscape pendulum swing in 32 years in healthcare IT and 40 years in healthcare, but the most important thing we need to do is make sure that our data sources are broader than just what’s happening in a hospital setting. We need better data from long-term care facilities and ambulatory care facilities. Behavioral health has been a big challenge in terms of effective health information exchange. We have a number of initiatives that address those issues, working with some of our HIE partners. If you look at the community and who is really impacting a healthcare consumer, it is a very diverse group of folks, including a lot of social service agencies. All of that data is critical for improving outcomes, particularly with those communities that need it the most.

After all those  years in the industry, what aspects of it are you enthusiastic about?

We are entering a golden age. We are overcoming some of the last hurdles, from a business perspective. Even though I complain about the proliferation of standards, the positive side of that is it gives us an awful lot of tools in the toolbox to address specific healthcare workflows and use cases. We have a lot of talent coming in from an engineering, a lot of younger folks coming into this part of the space who enjoy problem solving. I’m really excited, and while I realize there are problems that have been around for a long time, we have a lot of great minds working on them. There have also been a lot of advances on the infrastructure side that give people options. We are going to be able to accomplish more in the next five years than we’ve accomplished in the last 20.

Do you have any final thoughts?

Zen has been a pretty well-kept secret for years. To help fuel our growth over the next couple of years, we’re going to be working hard this year to share some of our clients’ successes as a testimony to the value that we bring to our clients and to the industry. We’re going to continue to grow and evolve our solutions to keep up with what’s happening in the industry, with a continued focus on FHIR, API, and National Trusted Exchange. But the most important thing we’re going to be doing is continuing that laser focus on making interoperability easier for clients so that they can stay focused on what they do best. Our best day is when one of our clients makes a difference in the life of their patients or in the healthcare consumer. In the last year, that has never been more important. It’s an exciting time to be in this business and we will continue doing the best we can for our customers every day.

HIStalk Interviews Brian Schmitz, CEO, Clinect Healthcare

Brian Schmitz is founder and CEO of Clinect Healthcare of Charlotte, NC.

Tell me about yourself and the company.

I have 20 years in healthcare IT and the company is 10 years young. With Clinect Healthcare, practices and health systems can collect, monitor, measure, and act on their patients’ experience throughout the cycle of care, pre-, during, and post-encounter. We provide an integrated mobile-first and fully automated approach for intake, patient-reported outcomes or PROs, and patient experience, as well as provide the tools to gain insight and to act on patient responses in real time.

What kinds of technology solutions have become important during the pandemic?

People ask me, how has COVID impacted your business? I say that it doesn’t matter. How has it impacted our customers’ business and what technology are they asking for that allows us to help them?

As a case in point, one of our intake and PROs customers is expecting to have north of 20,000 new patients during Phase 1B alone. The same customer will see 832 patients today because of the Pfizer vaccine compared to 184 new patients one year ago today. There is a wave of new patients getting ready to descend on practices. We’re talking about the largest scale vaccination attempt in modern history. A positive patient experience for that new patient could translate into a long-term customer, so I recommend measuring their patient satisfaction and giving them a chance to feel important throughout their vaccine journey. Patient acquisition is in play.

But anecdotally, we’re seeing more and more technology interest to measure the efficacy, measure the side effects within the practice, but oversight of those patients is key. Using a PROs type platform where providing the automation, integration, and outreach to follow the journey pre- and post-injection. A learning based on response thresholds is also  important. But the best part is that we have patients’ clinical artifacts — age, chronic conditions, medications, allergies, et cetera — from the EHR. Marrying up those with PROs feedback for analysis is priceless.

Suffice it to say, healthcare systems and practices will need to prepare for high patient volume with COVID and the COVID vaccine. Intake solutions will be convenient with the influx — I get it, we offer it, too — but PROs are critical to drive value-based change and increase revenue. That is true beyond COVID. It is diagnosis- and specialty-agnostic, but that’s the type of technology that we’re beginning to see from a remote patient monitoring perspective within COVID.

How are providers, especially the smaller and less sophisticated practices, managing COVID-required activities such as selecting patients for the vaccine, notifying them, reporting the injection, and following up for their second dose?

There’s a behavior change and heavy lift that’s going on, both within the electronic health record vendors and working with the providers to ensure that we are able to collect new information within the medical record chart and PM system, as well as report those that fit the criteria for that next phase. Working within those confines, and working with the reportability of those systems, is key for the reach-out of bringing those patients back into the practice.

How will the tracking of vaccine side effects work in terms of patient-reported outcomes?

The PROs, the patient-reported outcomes side of it, is driving the need to measure what’s going on. We are finding that there are a lot of unknowns out there as it relates to the efficacy rate of these particular vaccines. Being able to leverage technology to have touch points post-vaccination throughout the first shot — how are you doing, how are you feeling — past the second shot. Identifying side effect information is very important. Healthcare systems and provider practices are just now understanding that this is an important thing to measure, and they’re looking at technology in order to automate that process and to bring information back to them in real time so that they can act on anything or any threshold that is out of bounds.

What is the state of the industry in using patient-reported outcomes to drive follow-up workflow on the back end instead of waiting for them to call with questions or to make another appointment?

Taking a proactive approach and engaging the patient is the key to getting more real-time understanding of what’s happening with the patient. As an industry, we’ve done a decent job of creating point solutions for interacting with your healthcare providers on an administrative level – portals and online scheduling, web payments, and so on. That’s a reactive approach. It’s time for the patient to have the opportunity to have a discussion with their care providers that is a proactive approach into their world. We’ve shaped our platform to do just that. They will engage at the conversation feedback level, where questions can be asked and responses can be acted on, in and out of the examination and the procedure room.

Is the coexistence between EHR vendors and third party solution providers better defined than in years past?

It is. We have great partnerships, from a data integration perspective, with the top PM and EHR companies that are out there, and the working relationship has been great. In fact, with COVID, we’ve formed a strong collaborative with a top EHR vendor and the health system that we worked with to ensure that the integration is in place and the data collection that we are taking is being consumed by the electronic health records in a meaningful way. I think they know where their space is, and they recognize that our solution complements the ability to reach patients both in and out of the office.

COVID has shown how archaic the process is of stacking up patients in waiting rooms or in the checkout line. How well have we used technology to streamline that?

We have advanced it so much over the years because the nature of what we want to learn and collect is changing. Even when looking at COVID, for example, the waiting room has extended into the parking lot and into the cars of the patients. So the timing in which we collect information has shifted. The nature of what needs to be collected has changed.

This has allowed patients to become more comfortable using their devices. We subscribe to mobile-first, and I personally subscribe to the idea that the lowest common denominator of technology is a button click. Being able to provide an easy approach to documenting your health history and your insurance information, your demographics, as well as PRO information that is meaningful, scored and pushed back to the medical record chart has been adopted very well by patients. We’ve seen that over the years and certainly with COVID, it is becoming more and more accepted by patients to fill things out outside of the brick and mortar of a practice.

Is there a software opportunity in the higher abandonment rate of patients who get tired of waiting for their telehealth visit to begin?

There is. When we talk about telehealth, we’re talking about a remote encounter. We need to focus on is making the patient feel as though there’s an extension of that remote encounter. We want to capture information ahead of the visit that will be meaningful for the provider to have. W want to monitor that patient to follow up with the their diagnosis. A solution that can complement a specific telehealth visit allows us to provide more of a holistic approach for the patient, both pre- and post-telehealth visit, for better care overall.

Who will be the driver of tools and processes for that interaction – primary care doctors, hospitals, or insurance companies?

It falls at the provider level. We are seeing a lot of interaction right now with payers that are interested in gaining insight and learning best practices, best techniques that could then be relayed down to their provider base. But there’s a lot of specificity to what PROs provide. With value-based care, it’s going to be very important at the specialty, practice, and health system level to measure their patients to identify the best techniques and best practices that work for us, that we can then also educate the patient on so that they can be more engaged into their care. A healthy patient is a more profitable patient. It gives us an opportunity to measure that at the local level so that they can act, because that is their patient and the relationship is within that patient.

Do you have any final thoughts?

Given the state of technology, as well as the sudden shift where remote and electronic interaction is acceptable and required in some cases, the cycle of care can be even more continuous and less episodic. Sitting in an exam room isn’t the only place where critical feedback can be received any more, but it needs to be simple for patients and easy to access for staff. The use cases with a platform like this are endless.