HIStalk Interviews Drex DeFord, Healthcare Strategist, CI Security

Drex DeFord, MSHI, MPA is healthcare strategist for CI Security of Bremerton, WA.

Tell me about yourself and the company.

I’m a recovering CIO. I have been a healthcare executive for most of the last 30 years and an independent consultant for the past four or five years. I serve as the healthcare strategist for CI Security. CI Security is a group of world-class security professionals who provide managed detection and response and cyber consulting services, with a mission to secure critical systems. We specialize in healthcare, but also cover other critical infrastructure.

What are the takeaways from University of Vermont Health Network’s month-long downtime from a cybersecurity incident?

This is one of those situations where the breach occurred long ago. The bad actor was in the system for a long time before they ultimately wound up revealing themselves. That’s part of the challenge today.

Historically, we have worked hard to build high castle walls to keep the bad guys out. But what we’ve realized, at least in the last few years since ransomware became prevalent, is that all of your frontline employees are now frontline cybersecurity people, too. One wrong click going to the wrong website and you’ve been breached.

You feel like you have to meet this challenge of building a tall castle wall, but the real opportunity is to find those bad guys as soon as they’re behind the castle walls, catch them, and throw them out. That’s a lot of what managed detection and response is about. Whether you’re in a big place or a small place, rethinking the strategy around security is critically important.

Is it true that human hackers aren’t involved until sometime after the technology back door has been discovered or opened via mass Internet probing?

This is another way that cybersecurity and attacks have evolved over time. You can certainly have nation state attacks, but now there’s ransomware as a service. We often find that health systems or other organizations are hit by ransomware as an accident. They are just collateral damage. Somebody was trying to make a quick buck, punched out a bunch of ransomware, and somebody in the health system clicked on it. It wasn’t directed, it wasn’t intentional, and it wasn’t focused on that health system. It’s just one of those things that the organization found themselves wrapped up in. 

As the types of ransom market and attacks evolve, we will see more and more and more of that, where it’s not really aimed at a health system or hospital, but the cybersecurity posture of many health systems leave them vulnerable to these collateral damage attacks.

How can CIOs convey that threat to board members who might see it as theoretically possible but so unlikely that it doesn’t warrant funding and focus?

A lot of this is keeping your board informed and helping them see the negative results on competitors or other organizations. Boards and other executives are very involved in this now, from what I see as I talk to CIOs across the country. Every time there’s a SolarWinds attack or something like that, board members start sending questions about, are we covered? How are we doing? Is everything OK?

You are right that it’s hard to prove a negative. If you’ve been doing a good job in your cybersecurity posture and you haven’t been breached, there’s still plenty of story to tell about the number of taps you’ve forwarded and the number of ransomware emails that don’t get through. A lot of those things are still happening to you, but you’ve been doing a good job of catching them. Those are the stories you should be telling.

Is healthcare more at risk because the many hospitals that are outside of big cities won’t have a lot of local cybersecurity expertise available and might not have the money to develop it?

That’s a real challenge in most places, especially with small and medium-sized health systems. The talent problem is real. It’s tough enough to try to hire the hire the people and get them to move to these areas. But once you get them there and you start teaching them some of these cybersecurity tools, you’re apt to lose them quickly, too. Retaining good talent is tough.

The other challenge I see over and over is that lots of vendors have silver bullet products that they would like to sell to organizations. The organizations get them, install them, and run them, but then quickly start to realize that it’s going to take more than a fractional FTE to actually get value out of that product. After they have accumulated a whole plate full of these products, they realize they have created a situation where they are more exposed. They know about these things, but they can’t do anything about them, or they don’t have the talent to actually run those products.

Being able to bring somebody in and let them do management section of response for you, 24/7/365, is the other big gap that we see. But being able to do it 24/7/365 — and having wraparound professional services that can help you get started through things like security, risk assessments, and penetration tests and all the other things that can be combined into a single package — makes a big difference to small and medium-sized health systems. They just don’t have the people to handle the challenges that face them. It’s not a core business skill that they would normally have.

Have recent incidents raised an awareness that cybersecurity breaches aren’t just an IT annoyance but in fact could put a hospital out of business?

There’s a cybersecurity and risk continuum that ranges from not very mature health systems to mature ones. There’s an understanding, or lack of understanding, that it’s not just about being hacked, It’s about the impact to the business. Short term, you have to get the systems back up and running and help get patients get back in. But long term, there’s the reputational impact. Especially for not-for-profits that have fundraising arms, being able to instill confidence in your donors that you’re a good place to donate money to because you take good care of patients and families and you never let them down. That’s how cybersecurity is tied to everything else, because it really isn’t standalone.

A simpler, relatively modern infrastructure is way easier to secure than one that has been built haphazardly over a number of years. That includes even infrastructure projects, upgrading switches, and upgrading end-user user devices. It doesn’t have to be bleeding edge, but that maturity and understanding makes the difference between mature organizations and relatively immature organizations.

Attacks in the past were usually focused on widely present misconfiguration vulnerabilities in JBoss servers or Windows Remote Desktop, where if an organization was paying even modest attention it could protect itself. Have attack methods broadened, and how do healthcare organizations share information about their experience and actions?

Trying to protect yourself against yesterday’s attack is a good thing to do, but lots of new types of attacks happen every day. It also comes back to doing simple, straightforward things. If you’re a CIO, you need to make sure that your network, server, and application teams have the time to apply patches to reduce your vulnerability. Cybersecurity is connected to everything else, including operations. Healthcare has gotten a lot better at sharing information through organizations such as CHIME.

H-ISAC – the global, non-profit Health Information Sharing and Analysis Center that crowdsources cybersecurity — has become a critical component in the sharing of cybersecurity information. You do preparatory work, such as doing tabletop and full-blown exercises where you connect to the organizations that you may need help from. You want to have your connections – such as state police, the FBI, or other healthcare organizations in your area – in place and on speed dial so that you are ready to connect. That’s not something you want to figure out after you’ve been breached. More connections and more collaboration puts you in a better position from a cybersecurity perspective.

ISACs exist for different industries and healthcare has a great team there who are always looking and working closely with the FBI, HHS, ONC, and others. They log, catalog, make recommendations, and share information about the kinds of breaches that are occurring.

It’s another reason too think about managed detection and response, because if you’re a standalone medium-sized hospital, you’re working off only the connections that you’ve been able to make as a small shop without a lot of time. A professional service organization like ours has lots of connections, not only in healthcare, but in other industries. This is what we do every day, so we are more likely to be looking for problems or openings for the bad guys that you may not have even heard about yet

What are the security risks involved with vendors and providers making initial moves to the cloud?

A cybersecurity professional company can help you navigate these waters. We have seen health systems, time after time, assume that software as a service means that if I don’t run this on my premises, and instead have it run by a company who does it for a lot of other people, I should be more secure. Generally speaking, that’s probably true, as long as you’re doing all your due diligence with that third party to make sure that they’re doing all the things that they should do to be secure.

When it comes to the cloud, the true cloud, this is another one of those situations where there are opportunities to make mistakes. You’re probably going to be more secure than you are. If you try to do it yourself — especially if you’re a small or medium-sized health system — engage a professional to look at the vulnerabilities and make sure you’re covered for what you’re trying to do.

Do you have any final thoughts?

CI Security is happy that 2021 has arrived and 2020 is in the rearview mirror. Cybersecurity is in front of boards and healthcare leaders.We look forward to supporting the need for critical healthcare infrastructure with easy to understand, easy to consume cybersecurity services and managed detection and response that is packaged up to be delivered in a better, faster, cheaper way.

HIStalk Interviews Diana Nole, EVP/GM, Nuance Healthcare

Diana Nole, MBA is EVP/GM of the healthcare division of Nuance Communications of Burlington, MA.

Tell me about yourself and the company.

I run the healthcare division for Nuance. I joined the company in May, but I have known Nuance for about 15 years, which was right around the time when I started my work within healthcare, always being around technology and companies that were transforming their portfolio. This is a great opportunity. Nuance is well regarded in terms of being respected by customers. They have a large installed base, wonderful partnerships with everybody that’s in the ecosystem such as the EHRs and Microsoft, and a lot of great growth opportunities. While I wasn’t looking, it was an intriguing opportunity and time to come to the company.

Where would you place ambient clinical intelligence in your personal version of the hype cycle?

We are in the earlier stages of how it will be used within healthcare. It is focused right now on the particular area of physician burnout and patient experience.

The elements of the documentation burden that is placed on the physician is causing them to feel overwhelmed. They are not being able to produce the type of experience they want with patients, but patients are also feeling disengaged. This is a solution that is going to evolve from not just being the element to fix or to support better clinical documentation, but to expose opportunities that we haven’t appreciated or realized. 

For example, wouldn’t it be helpful to have the complete diarized elements of the conversation between patient and physician for other people that are supporting the patient in their treatment plan, perhaps family members? My specific example is that my aging parents go to the doctor. It’s not always clear what the doctor has asked them to do when they get back home. As a family member, wouldn’t that be great?

We are in the very early stages of how we see the uses and the use cases of this. The technology needs to continue to mature when you think about ambient and conversational AI versus more structured use of voice recognition.

Does a model exist in other industries that healthcare will follow, where software extracts discrete data elements from a conversation between a professional and their client?

Nuance used to be directly involved with conversational AI that took place in an automobile. It had to distinguish between conversations that were going on in a car and the aspects of what should be done with that communication. We have leveraged that a lot within our own organization. We are starting to see other interesting use cases. We also participate in law enforcement, where we can capture the conversation that’s going on and understand where that might be applicable.

How do you see that diarized speech of basically the full transcription of the patient encounter being used?

We are intrigued to see where that area evolves. As I mentioned, there’s definitely a use case where the patient may want to be able to provide that to other people who are of interest. There has always been a bit of a worry about whether that will open up even more concern about what is said and whether that will tamper the conversation and constrict it. There are elements of compliance and concerns about what gets said.

It’s not necessarily the direct clinical elements of the conversation, but maybe more of the conversation that is not directly related to the medical outcome for the patient or the treatment planning. There will be people who will be concerned that, “If I didn’t say this, will it come back to haunt me?” but I believe that we are at a point where the benefits can outweigh those risks.

The industry at large is being more open minded. In our first use cases since the product became commercially available 10 months ago, there is definitely an appreciation, even by the physician, that this is beneficial for them as well. They can’t always remember everything that is communicated, so if they aren’t transcribing or doing something in the course of the actual patient visit, could they have missed something? It is beneficial even for their own purposes to remind them of what was discussed and said. Those users have said that it is helping them to improve the quality of the documentation that’s provided.

We are going to see where it evolves, but I’m definitely pleased that people on both sides, patient and physicians, seem to be open minded about the benefits of the full diarization of the conversation.

What are customers doing with Dragon Ambient EXperience, or DAX?

They have fully deployed it. We have evolution of the maturity levels in particular specialties. Orthopedics is probably the most advanced, but they are fully deploying it.

What’s been interesting in the COVID era is that they also have been deploying it, in many cases, in a telehealth environment in addition to an office environment. Some of them use the mobile app, while some of them actually use the office device that we have. They have typically rolled it out to anywhere between 15 to 25 doctors. They see the process and change management that is associated with it, which is very limited in terms of burden to them. They are up and running right away.

Then we are already into the elements expansion and going into maybe more orthopedics in a particular location, going to the entire department, or they’ll go into the other specialties as we’ve been maturing them. It is an element that continues to include a quality review process as part of that, as that helps the ongoing algorithm in AI and the neural nets that … I can’t describe it to a deep degree, but all of that is continuing to be fed back and making the process more and more accurate. So it’s gone quite well.

What preliminary results have clients seen with regard to physician burnout?

We do data analytics around turnaround times and patient satisfaction. Before DAX, roughly 72% of physicians were feeling burnout and fatigue. After DAX, that was reduced to around 17%. We get quotes that just the thought of taking DAX away is stressful or would make them want to quit.

We are definitely seeing reduction on the physician burnout side and the benefits we offer, but patients are also describing more engagement from the physician. They feel more attended to and feel that they are being listened to. We have also seen patient wait times down, maybe about 10 minutes, which is almost 50% reduction in wait time, so it’s also an element of either being able to have the opportunity to see more patients if a physician wants to do that or to utilizing the time to feel less overwhelmed from an administrative perspective. Early feedback has been quite positive.

I assume the patient’s perception is due to the clinician paying attention and looking at them instead of typing while they are talking.

That’s exactly right. It is an element of feeling like I was listened to — you weren’t distracted. There was feedback that almost all patients are saying that the physician spent less time focusing on the computer. Very high percentages, 90%, said their visits felt more like a personable conversation. The patient elements are also very satisfactory for the physician.

Technology can now make talking to a machine seem like talking to a human, and people are comfortable interacting with virtual assistants in ways that can border on the scary. Does that capability provide new healthcare use cases?

There are a few different cases, so you are exactly right. One of the exciting things that I learned when I was going through my interview process was the opportunity within Nuance to focus on intelligent engagement, as they referred to it. We use that a lot on our enterprise side, but we recently have launched it under the umbrella of patient engagement solutions within healthcare. We have some early wins in terms of customers that we will be announcing soon.

We are focused on exactly that. Customers have reached out, in particular COVID providers, and said, “We are completely overwhelmed with calls coming in with patients wanting to understand their options. ‘Can you just remind me what am I supposed to be doing? If come into the office, where am I supposed to go?’” These basic things potentially restrict a patient from following up for treatment and getting things done if they can’t find easy access to the information that they’re looking for. We are excited to be taking this technology from the enterprise side and doing more with it in intelligent engagement.

People are also thinking about how to use DAX, the ambient clinical intelligence solution, for example, an inpatient hospital room. You could have more interaction and diarize that with multiple providers within a patient room, where the patient could interact with it. They are also asking if it could be viewed as being an ambient opportunity for check-in, where you don’t need so much human-to-human contact and could check in via the ambient device in a particular check-in room.

I don’t know how many of these things will immediately stick, but it’s interesting that people are thinking about where else it can be applied.

Speech recognition is now ubiquitous, accurate, cloud-based, and accepted by consumers. How does that support using it new ways?

We’ve talked about speech, particularly on the healthcare side with the physicians. We’ve also been working on solutions for other parts of the care teams, such as nurses. In many cases, nurses provide the same kinds of things, but in different ways and in a different structure. We have talked about the patients and the intelligent engagement. It’s an element of the environment. What is the setting? DAX has initially been rolled out as an office visit type of setting, where there is a tremendous amount of clinical documentation burden. But obviously the interest would be how to do more of that in the hospital inpatient setting or in other types of clinical settings. People have also asked if it will be more interactive in areas such as mental health.

It will evolve. I don’t want to get over our skis a little too much here, because there certainly is a lot that goes in just with the initial use cases. But certainly as you said, people are now saying, OK, it’s not just hype. It really does work and it is going to evolve. There are opportunities to deploy it into these various use cases, which I’m excited about. Especially in a COVID year, to see the ongoing investment in evolution of has been motivating for me and certainly for our team.

Do you have to evangelize the idea of developers building software with speech recognition as the primary input mechanism instead of just bolting it to keyboard-centric applications?

There is enough evolution that has occurred on the consumer-oriented side that you have to do less. People believe that it’s there, it can happen, and it can work. There is an element of skepticism of how well it can work in a clinical documentation setting where you have to be highly accurate. Not pretty highly, but highly accurate. You’re going to use this not just for coding and reimbursement, but for the treatment of the patient. There is this element of prove it out, prove it out in all of the specialties, and prove it out beyond the structured specialties that we have initially focused on.

People ask, how well does it work in family medicine practice, where you do have such random things that you might be seeing the doctor for? I fell this weekend when I was skateboarding and broke my ankle. How does that relate to all of my past history, and how is it going to interact with all of the various elements of what the doctor needs to think about when they are prescribing treatment or patient outcomes? There is a belief that it will get there, but there is also a bit of skepticism on remembering how difficult it is for some of these use cases with particular specialties, and every patient situation is quite different.

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

The heavy focus is on reducing physician burnout from the specific element of clinical documentation. But then as your comments and questions have mentioned, what can you do in the course of hearing something from a conversation? What could you actually do?

For example, three to five years out, could you have the computer help the physician with reminders in the course of that conversation with the patient? Like surfacing things that it may hear that you need to be reminded of. Such as, remember for this patient in their medical history they had XYZ. And coming from a company that I just left in Wolters Kluwer, there’s a new topic in UpToDate that would be applicable for this particular conversation, would you like to look at it?

The elements of how broadly you can take the conversational AI and incorporate it with the information that’s residing either in clinical decision support tools or in the course of the actual medical record for the patient will be intriguing. Then, how you can continue to be better and better at structuring the clinical documentation so you can do more data analytics and predictive analytics and tie it into things that go as far as into the world of life sciences initiatives. It does start to open up the creative ideas of what could happen and what could be out there in the future.

Do you have any final thoughts?

Even during the challenging time that we’ve had with the pandemic, I’m optimistic about what I have seen occur during this time from our customers. They have been able to adapt to this change and take on new technologies, such as those associated with telehealth and beyond. We are going to come out of this a stronger industry.

HIStalk Interviews Luke Bonney, CEO, Redox

Luke Bonney is co-founder and CEO of Redox of Madison, WI.

Tell me about yourself and the company.

Redox is the world’s leading cloud integration platform for healthcare. We help great healthcare technology companies integrate with thousands of providers on our network. We accelerate the adoption of these tools at healthcare organizations across the country. We are live or installing at 19 of U.S. News & World Report’s top 20 health systems across the country.

I am first a husband and then a father of two. Zeke is our son. He’s two and a half. Leona is our eight-week-old daughter. Our chocolate lab is Leroy. We call Madison, Wisconsin our home.

Large health IT vendors are partnering with cloud services such as those offered by Amazon, Google, and Microsoft. What opportunities or challenges does that introduce?

We see that as a massive opportunity. We see healthcare embracing the cloud as a key to the overall realization of bringing technology innovation into this space.

The whole bet of Redox from the very beginning  has been on the cloud. When we got started back in 2014-2015, we had to say “no” 100 times in order to get one “yes.” That was because we refused to compromise on that vision of the cloud being a key component to what healthcare was going to need in the future. We saw that initial inflection point of healthcare as an ecosystem getting more comfortable with the cloud sometime in late 2017 and early 2018. That’s been a big trend that has accelerated Redox and all of our customers.

As provider organizations pick and choose the technology that they see as adding the most value, a a greater and greater percentage of those companies that they work with are cloud native. Whether they are hosted in the cloud or not, they are cloud native. More and more of them are SaaS based, fully managed services that they pay a subscription for. We see that as a massive change that will allow healthcare to catch up to how the rest of the world sees the technology and innovation sector working.

The industry’s news is filled with unfamiliar company names that are creating buzz and investment activity. How much of that was driven by technology advances versus business needs?

Digital health as an investment sector has been growing at an accelerated rate for the past five to seven years. That’s a predictable extension of what we have seen over the past four to five years, with an accelerant being that the world now has a clearer understanding of the importance of technology in healthcare. That’s because so many of us have come face to face with it as part of COVID. How many people have had their first video visit with a doctor, or scheduled online for the first time with their doctor, because of COVID?

The trend has been pretty consistent. The difference in 2020 has been that we’ve seen a lot of investment come from outside of healthcare. People who haven’t historically invested in healthcare and digital health are starting to write pretty major checks. That goes hand in hand with provider organizations being more comfortable purchasing tools, purchasing technology, that is hosted and built in the cloud.

The big EHR vendors don’t get most of the splashy headlines or credit these days, but their decision to open up their systems fueled these other capabilities in allowing these upstarts to connect. How do you see that model playing out?

Redox has always had a vision that healthcare is best served when there’s a thriving ecosystem of technology and tools, whether we’re acting as patients, providers, or administrators. Single, large incumbents can solve many of healthcare’s problems, but they will never be the best at solving a long tail of what those problems could look like.

We’ve always had a vision that the role of the EHR will always be critical. There will always be a core need for data. There will be a core need for closed loop workflows. But we also see what we’ve experienced so far, which is the explosion in third-party applications that add significant value, that have targeted tools, that have targeted workflows. Regardless of the incumbents or the situation, we’ve always seen the demand for this kind of thriving ecosystem.

This is where our vision and that of regulators are aligned. We need an open and thriving ability to integrate data, wherever that data might be. We are excited about where the 21st Century Cures Act and TEFCA, these big pieces of legislation, are pointed. This is what the industry needs and what we have been building towards all along. We see it as a significant accelerant to what we do and to our ability to help a growing number of customers.

What impact will result from the Cures Act’s API requirement?

The exciting thing is that it is already changing the industry. A lot of the major EHR vendors who are at the center of this regulation are moving faster than expected. There are major pushes to enable FHIR endpoints and to help large provider organizations turn them on and start to use them. We’ve seen a number of delays in the enforcement of things like information blocking and some of the API mandates, and those delays make sense given the impact of COVID, but we see some of the major groups in this space leading that instead of lagging behind.

What that means for us as people who focus on integration is that we’re seeing a slight uptick in the total number of integrations that we can support as we embrace FHIR. FHIR won’t be a panacea that solves all the different problems and there’s a ton of complexity that remains, but it is definitely a step in the right direction. We are focused on that.

We’re also excited about looking at the opportunity that the Biden administration has, specifically looking at TEFCA, which is not yet finalized. There’s an opportunity to put some real teeth into TEFCA. How do we build this idea of a network of networks where data can really be liquid? As we look at TEFCA and understand the world that it contemplates, we get excited about how that could accelerate the overall adoption of technology in healthcare.

Where the regulators are pushing the industry is highly aligned with where we think things need to go. We are positioned to be helpful and to continue to provide great service to our customers.

What interoperability shortcomings has the pandemic exposed?

We saw demand for healthcare technology narrow dramatically in March, April, and May. The digital health and healthcare market is like 30 technology categories, and about 25 of those were put on hold, while five had unprecedented demand — telemedicine, remote patient monitoring, anything related to diagnostics, anything related to automation where folks could save money. While there was this extreme narrowing of demand, the urgency was unlike anything we had ever seen. We were putting integrations into place that would typically take six weeks in 3-5 days because of the clear need for those technologies

One of the most amazing things we experienced back in Q2 and Q3 was the sense that everybody was willing to pitch in. Everybody understood how dire the situation was. We brought together 15 applications from 15 vendor customers of ours and offered a free package to healthcare organizations that includes the tools that they could need or would need to combat COVID-19. Everybody was clear on what we needed to figure out with incredible urgency.

We also saw, and this talks directly to some of the current archaic methods of integration, that we had to make a big shift, because there was clear demand to do types of integration that we’d never done. Our historical bread and butter is helping technology organizations integrate with provider organizations and their EHRs. What we got asked to do was to work more with groups like LabCorp to support lab workflows.

We also had customers who needed to be able to report COVID results to public health agencies at the state level across the country, so in about two and a half or three months, we built infrastructure in 48 out of the 50 states to report COVID results. We built it because it didn’t exist. We didn’t want to. We would have used things had they already been there, but we built it because it didn’t exist. For Redox customers that are providing COVID testing capabilities, we are processing 10% of all the COVID tests in the country, looking at the volume of results messages that come back across our platform. That’s number one. It’s super interesting.

We are thinking about whether the same infrastructure that we put in place to support a lot of this diagnostic testing can be valuable or helpful as we look at rolling out this massive vaccine work, which will include administering and tracking vaccine distribution.

We’ve seen a lot of change. We are doing integrations that we’ve never done. We are doing it at scale. It has all been because we, along with everybody else, have felt that we have a role to play in helping the country and the globe come back from COVID-19.

How does the changing demands, employees working from home, and your significant investment funding guide you in planning what happens with the company next year?

There’s an art and a science to that question. This is a big part of what we have been focused on. The first is taking this view of how we can support those different categories of technology. One of the big things we will be doing in 2021 is sharing much of what we’ve learned over the thousands of integrations we’ve done, offering those as packages to our customers so that they can go so much faster. If there’s one thing we learned in 2020, it’s how to do things faster than we’ve ever done them. We want to share that learning.

The second big thing is that we are excited about a couple of our big partnerships. We are working with Salesforce as one of the only certified integrators to help stand up and streamline integration into their Health Cloud product. We recently announced a partnership with Amazon Web Services, speaking of cloud hosting providers. We are making it a lot easier for anybody who is either  using AWS or planning to purchase AWS to use Redox and to purchase it straight off the AWS marketplace.

The third thing is the exciting announcement that we will be talking about in February. I can’t tell you what it is because my marketing team would be very upset with me, but you should come check out our event in February, where we will talk about some product work that we will be releasing.

Do you have any final thoughts?

2020 has been a remarkable year. We have seen a lot of collective pain and suffering, but it is inspiring to see how parts of society have responded. We were inspired by all the work folks are doing as it relates to social justice and Black Lives Matter. We are inspired by the speed at which the global workforce adopted working from home. We are inspired by how quickly healthcare adapted as COVID took hold.

I would just end by saying that 2020 has been a really long year. Here’s to a great 2021.

HIStalk Interviews Robbie Hughes, CEO, Lumeon

Robbie Hughes, MEng is founder and CEO of Lumeon of Boston, MA.

Tell me about yourself and the company.

I’m an aerospace engineer. I’ve been a computer geek all my life. I was particularly interested in the problem of the computerization of industries versus the digitization of industries. That led me when I was still a student into the law, accountancy, and healthcare. All of those industries were activity-based in their reimbursement forms, and all I saw was using computers as expensive typewriters rather than the way I’d been brought up to use them.

Characterize me as a computer geek who was naive enough to think I could get rid of variability in healthcare delivery and stubborn enough to stick at it for now 15 years. But the thing that interests me, and the thing that got me into this in the first place, was, how do you deliver a common standard of care across a network? That’s the variability problem I’ve been going after all this time.

Lumeon is an agility layer that sits on top of the EHR. It helps providers personalize and operationalize a common standard of care across the enterprise. The people who buy that tend to be interested in doing something different, innovating around an operating model, innovating around a new way of delivering care. That lends itself in particular to risk-bearing entities who want to principally use automation to cut out costs and transform care. That’s a lens that we bring to it.

We started in Europe. We moved over to the US, and obviously there’s a huge amount of difference between those two environments. But there’s also a huge amount that is similar, so we’ve been lucky to be able to isolate a lot of what’s common between the two and bring it from one environment to another in a relatively interesting and different way.

Are providers interested in standardizing care when their patient population is a mix of fee-for-service and value-based care?

Absolutely yes, but we need to be really careful about the language. What we don’t do is standardized care. What we do do is standardize decision-making that results in the personalization of care. So the problem as I see it is not how to do the same thing to every patient, it’s how to apply a common standard or apply the same decisions in the same way to every patient. That results in the appropriate application of the right care to the right patient, which in a fee-for-service construct, very happily is usually reimbursed.

The effect we tend to see is not only in elimination of waste — which is good in both environments — but also an increase in throughput, which tends to increase reimbursement and revenue as well. We’re in the slightly strange position of being able to drive up revenue in a fee-for-service environment as well as cut costs in both the capitated or risk-sharing environment.

That’s the core of what we do. It’s basically ensuring that every case, every patient gets the right care, and because the fee-for-service model reimburses the right activities, generally speaking, you will find the reimbursement goes up.

Is it hard to get enough information from the EHR to allow you to provide the best recommendations for all patients?

It’s very difficult. The way we do it is what we think is a little bit easier. I’ve been doing this long enough to know that you don’t try to eat the whole elephant in one go. When we started out, we would go off and do 100-site enterprise deployments that would take two or three years to roll out. Whilst that was, let’s call it educational, I wouldn’t describe it necessarily as fun.

The approach we’ve taken instead is to try to think about what is a digestible version of that problem that can be applied quickly and that can deliver value quickly for the customer, so that you never actually need to solve the problem of, what is the entire universe of care for every patient and every possibility? I don’t believe today that’s a tractable problem. Instead, what we tend to focus on is identify processes where there are gaps or discontinuities or grit in the machine, if you like. Then, how do you apply automation to that to deliver that lift, that personalization, but also that control and predictability to ensure that you are operating at peak performance?

You’ll know that the typical areas that you’ll find this will be around care transitions. For example, that will be around surgery and obviously in population health, where you’re trying to get large populations to do specific things, but each one of those things need to be specific to the individual. Those are the kinds of areas that we tend to specialize and see the most benefit.

Analytics-powered population health was mostly an aspirational legacy software vendor’s overused marketing term a handful of years ago. Has the definition or the expectation around PHM changed?

This was one of the really curious things to me when I came to the US a few years back. I looked at population health management as a category, and I thought, that’s interesting. That should be the application of the appropriate care to the individual at population scale. That’s what we do.

But the reality of the market seemed to be somewhat limited to meeting your quality measure obligations, and most specifically, looking at population health as an analytics and insight problem rather than an action problem. Population health management as a noun rather than a verb.

For us, the analytics are interesting. They tell you where to point the machine, but the problem we’re interested in is, how do you actually operationalize that? How do you solve that last-mile problem so you can drive the engagement, drive the personalization? Anyone can do the analytics with enough horsepower, but actually driving real change in a health system so that you are appropriately intervening with the appropriate patients with the appropriate care at the appropriate time — that’s a hard and interesting problem. That’s the thing that gets us up every morning.

The pandemic has possibly set us back, where we’ve moved to video visits that may be disconnected from the the patient’s usual providers and interrupting their normal health maintenance activities. Has care coordination suffered, or has the pandemic done us a favor to show us what we need to change?

Telehealth is probably the most interesting version of this care coordination problem. Health systems have lurched towards swapping face-to-face visits with video visits, which is a fine and a reasonable thing to do. But what nobody’s really thought about, or at least nobody that I can see has really thought about, is the governance around this.

When is it appropriate to have a telehealth visit that is provided virtually rather than a visit that’s done face-to-face? When is it safe to do so? What are the benefits? What is the standard of care that might be reasonably considered in a remote or in a face-to-face environment, how are they different, and what do you need to do differently?

For me, the orchestration of virtual care and the safety netting of it through the use of a combination of remote patient monitoring, screening, or any number of the other myriad interventions that exist for us today is the ultimate care coordination problem. It isn’t just now a problem of, “this patient is due for their flu shot” or “this patient is overdue for their colonoscopy.” This is now a problem of, for this patient and their presentation, that the next thing that they need to do is share this information, because it’s missing in their medical record. That will then tell us whether they can have the bit after that in this form or the other, et cetera, et cetera.

This orchestration of the fragments of care delivery is going to get dialed up to 11 if we are serious about using… I’m going to use the term virtual care, because I believe that’s different from telehealth in a meaningful way. I think that’s what the consumer wants. The consumer wants something that looks like every other industry, but there is a safety and a governance aspect to the application of these types of interventions in our industry that has not yet been, shall we say, road tested in any meaningful way.

I’ll bet there’s going to be a ton of lawsuits, not just in the US, but globally, next year from patients who have been misdiagnosed, mistreated, or forgotten about because of this very problem. When the dust settles from all of COVID, I think this is going to be one of the more interesting problems for the industry to address.

Much of the value in a visit is simply asking the patient how they are doing and using their answer to guide the next steps. Are we overlooking the value of allowing the individual to electronically document and contribute their own sense of wellbeing, activity level, or concerns?

One of the overlooked aspects of automation is that it should, if done well, enable hyper-personalization. For me, automation is not, at least not in our industry, about doing the same thing for every patient. It’s about looking at the marginal cost of every single activity and trying to reduce that to zero so that you can implement as many different activities as you possibly can to build up the most robust picture and then use that to drive the appropriate intervention.

In your example, I would advocate that the face-to-face consultation could be augmented by tele-triage in advance, whether asynchronously or synchronously, to determine the best use of the face-to-face time that that physician or clinician will have with the patient. It’s a perfectly reasonable thing to do. But in the case that it’s not face-to-face, you could apply the same model, but you can also look at other things.

If the consultation is face-to-face, for example, perhaps the patient has a sweaty palm, and as they’re leaving the consultation, they shake the hand of the physician and say, “Oh, just one more thing, Doctor.” That’s a classic pattern that, in a face-to-face environment, a physician would tend to leverage to gain better insight. But in a remote consultation, they can see that the paint is peeling off the walls, that they don’t have a chair to sit on, that they have 13 cats on the sofa, and there are people shouting in the background. You can build up a picture of the patient that is — I don’t want to say more complete or less complete, but suddenly different. The cues and signals that you look for in these environments are going to be different.

Again, not to say that either of these is right or wrong, but the important thing to realize is the expectation and the baseline that we set for care delivery in the “old normal” is completely different to what we might anticipate in the “new normal,” and we need to adjust. We need to design our interventions appropriately, and we need to recognize that the patterns, cues, behaviors, checklists, or whatever that we had previously are no longer going to be as useful. That’s a huge, huge opportunity if it’s embraced.

Again, this is kind of why I got into this. The trick is, how do you bring it together? How do you orchestrate it with precision? Because there is such a thing as the objectively right care for a given patient. It’s just that in this industry we tend to apply a lot more subjectivity to that than perhaps I think we should.

Will hospitals and practices whose capacity is once again being challenged by the pandemic respond by using those technologies that were rushed into service in the spring – such as telehealth and contact-free check-in – or will we see another wave of innovation?

We first need to come to a common understanding about what the core problem that we’re solving, and I don’t know that the industry has necessarily done that yet. People have applied the solution at hand to the symptoms that they see, but there is another level of optimization that needs to take place to create the sustainability and to create from scalability of even those same solutions and those same interventions before we get to another round of innovation. There’s a lot that can and will be done, but we have a lot to fix on the ground first. I’m not convinced necessarily that there is a universal view in the industry about what “good” looks like.

I would say that there’s the reimbursement problem which needs to be addressed one way or another, and obviously that’s going to drive a lot of behavior. Consumer expectations are being set. I think there’s going to be a lot of conflicting opinions around the level of reimbursement anticipated because the standard of care will be different. I think that’s an entirely reasonable debate, but I would advocate for much more freedom in terms of how people think about reimbursement, particularly around service lines and particular outcomes.

A lot of simplification can happen that will create innovation. I see a lot of complexity being introduced in order to manage some of the risks and bridge to value transition. Whereas if you look to other industries like the cosmetic surgery industry, it’s well published that cosmetic surgery and the cosmetics industry more broadly has been publishing a fixed price for a long time. Costs have been driven down there in an environment that is broadly similar to many other surgical interventions in healthcare. If we can get to a place where there is predictable pricing for predictable care, that will unleash a huge amount of innovation, and we will see a lot of adoption of all kinds of both operating models and technology potentially to support them. But everything begins and ends with money, so I would advocate for that kind of approach. I think if we do that, we will see the kind of movement we all want to see.

What changes do you expect to see with the company over the next three to five years?

The core emphasis of the company is on the US market. The core things that matter to us are around being aligned with our customers. I got into this because we have a very firm belief that it is possible to both take costs out of care and to improve the quality of care being delivered, however you define quality. Every time we’ve done this, the quality comes alongside cost reduction. I’ve yet to see a single example, over my many years of doing this, where the cost has increased and the quality has gone up. It has always been that the cost has gone down and quality has gone up.

That’s our North Star. The one thing we do, the one thing that drives us, is, how do we improve the quality and the consistency of what our customers deliver? Nothing else matters, really. If we do that, then our customers will speak for us. If our customers speak for us, then we will have commercial success, and we will create the flywheel that everyone wants.

But the healthcare industry is not one single, homogenous market. It is extremely diverse, extremely amorphous in payment model, operating model, structure, patient population, et cetera. It would be naive to suggest that one approach will work for each different environment. The customer intimacy that comes from the analysis we do, from the deployment work we do, from that strive for quality, is what makes us different and is what allows us to adjust for that. But I wouldn’t necessarily say that it’s a straight line path to success.

Anyone who gets into this industry who is trying to do anything, let alone any of the problems we’ve decided to solve for, is going to be in it for the long haul. But it’s nothing more than singular focus on that one thing, driving for quality and taking out waste. I think if we continue to do that in the way that we’re doing, we’ll all be successful, no matter what happens in the broader market.

Do you have any final thoughts?

It’s a fascinating time to be in this industry, and it’s a privilege to be able to work with some of the people we do. If I was to go back and give my 23-year-old self some advice, it would be to pick an easier problem to solve than trying to get rid of the biggest problem in the biggest industry in a country 3,000 miles away from where you’re based. But it is an absolute privilege to be able to do what I do, and if it didn’t work, I wouldn’t still be doing it. I’m grateful for the opportunity to talk to you and hope to be doing it for many years more.

HIStalk Interviews Kevin Coppins, CEO, Spirion

Kevin Coppins, MBA is president and CEO of Spirion of St. Petersburg, FL.

Tell me about yourself and the company.

Spirion is headquartered in sunny St. Petersburg, Florida. We serve the data privacy and data security markets. I joined Spirion just over a year ago. Before that, I spent the previous couple of decades working across a variety of tech companies, both in the cybersecurity space as well as in the networking space. I started way back when at Novell. 

With every role that I’ve held, I’ve had the opportunity to work with healthcare organizations across the US and around the world. Every company you talk to says they are different, their industry is different, or something is different. Healthcare is the only one that gets to carry that badge and actually mean it, because everybody else is much the same. Healthcare is definitely different.

How much information does the average health system have that they don’t know about or don’t realize is unprotected?

I typically start with a question. How much data do you have? Somebody tries to answer the question, and then they stop and say, we have no idea, because you don’t. Think about how fast data flows in and flows out, how it moves. It gets stored in the cloud, and then it gets replicated in the cloud, and you just don’t know. It’s a fair answer now, and people have gotten more comfortable saying that they don’t know. A few years ago, it was a little bit nerve-racking to acknowledge that you don’t know that.

The next question that you ask is, of the data that you don’t know how much you have, how much of that would be considered sensitive, and how do you define it? That depends on the industry, but healthcare will definitely go to HIPAA. Other industries will  go to GLBA or PCI. It depends on where they are regulated, because that’s where their brain thinks. You have to take a step back and say, that might be how regulation defines “sensitive,” but how would your patients define sensitive? How would your clients define sensitive? How would your board define sensitive? People take a step back and say, that’s interesting, we didn’t look at it that way.

First you have to define it. Then the challenge comes to, where does it live? Not just how much do I have, but where could it possibly be? That usually leads down another interesting conversation topic as well.

Is healthcare the worst of two worlds, where you have the legally defined protected health information, but you also have the business data of a health system that could be a multi-billion dollar enterprise?

Privacy is an overused term these days, but when you think about privacy, it’s fluid. How privacy is defined for you might be different than how it’s defined for me. It might be different how it’s defined for a provider versus an insurer. How that data is used or misused can also then help define what privacy means.

While regulations have tried to go ahead and put a fork in it, healthcare data back in February is different than it is today. I didn’t really care if the world knew what my body temperature was in February, but now, you could have a bias against me for having a temperature that’s not within the range that you’d expect. Or if you were to find out that somebody living in my townhouse complex was diagnosed with COVID, maybe then I’m not allowed to go to work the next day. A lot of information that’s associated — a combination of that PHI, but also proximity and demographics, et cetera — can be leveraged to help during a pandemic, but can also be leveraged after that to start doing some things that people might not be as comfortable with.

What is the biggest driver that might take a health system from going beyond being minimally compliant with HIPAA to having some enthusiasm about implementing tools and systems to protect data beyond what is legally mandated?

Every board across the US is waking up saying, how can I spend more money on something that doesn’t add direct value to what I do? [laughs] That’s the challenge of privacy security. CISOs deal with that challenge all the time. Vendors like us walk around and say, “If you don’t do it, you’ll be fined, flogged, and frozen and all these bad things will happen to you.”

Until organizations start making it personal, it doesn’t usually get traction. By personal, I mean recognizing that the data that you’re protecting isn’t some amorphous blob of sensitive data sitting in an Azure cloud store. It’s information about your neighbors. It’s information about your community. A lot of healthcare providers are community centric. Something happens to that data and it impacts the entire community, which includes your kids’ teachers and your own relatives.

A good example is that once your child who is under 10 years old has had their Social Security number compromised and used to get credit card, they begin their financial life in the hole. Then it starts becoming a little bit more real. There’s so many more ways than just identity theft in the ways normal people think about how privacy can be breached and how majorly impactful it can be when you start being impersonated by people online, et cetera, et cetera. Or you start getting discriminated against.

One example that I heard that is relevant today is that we’re supposedly getting closer to this vaccine. Let’s say the vaccine is rationed, and you have to meet a certain set of criteria in order to be to the front of the line for the vaccine. It would be pretty easy to figure out what that criteria are, mine for those criteria, and then sell identities that meet that criteria so people can go buy it and be first in line. Then when you go to get your vaccine, somebody says, “Nope, you’ve already gotten it.” Wait a minute, no I haven’t. That’s when it starts hitting home.

It’s really making it personal and shifting that gear to say, this isn’t just a nice thing to do it. It isn’t just a regulatory thing to do. It’s a critical thing to do. That’s when organizations start to shift.

Are hospitals thinking about security differently after the recent surge of ransomware attacks?

Yes, for sure. One of the first things they are asking themselves is, do I have a secure copy of my data, so that if I am ransomed and they want to shut me down, I can rebuild? The second piece is, how much data do I really need? How much of that is critical to my operations, and how much is non-critical? They are starting to think about data in a different way, because ransomware is either about shutting it down and saying, I’m not going to turn you back on until you give me something, or they will actually sell off your data. I’ve got all your sensitive data, and I’m going to release it if you don’t do something. The idea that data can actually hold you hostage is a new concept for boards to think about. That has started putting a different value on that data.

The unfortunate impact of that is people are paying a lot more attention for the wrong reasons, versus waking up and saying, we should do this because it’s the right thing. People who start solving for the privacy problem because it’s the right thing to do typically don’t have the ransomware and breach issues. They have solved it organically and culturally within the company versus as a by-product of something they think they are supposed to do because their regulator said so.

How does a health system reduce the risk that is associated with the data they discover?

The first thing is to reduce to the absolute optimal the number of copies that you need to have of that data, and then make sure that it can’t replicate itself. With cloud stores today, if you are looking at your laptop right now, it’s probably syncing to a OneDrive, Google Drive, or  Dropbox. When you save something, will save in the three other spots. Getting a handle on what sensitive data is, how that data can move, and how that data can be stored will be a big step in the right direction to solving the problem. We talk about reducing the threat surface of sensitive data, and you do that by understanding where it is and how much you have. You can only do that once you define what it means to your organization.

Healthcare is fairly new to the cloud and we’ve seem some inadvertent exposures because of incorrect cloud configuration. Is that situation commonly or easily detected?

A cartoon shows the son saying to his father, what are clouds made of, Daddy? And he says, mostly Linux servers, son. [laughs] It’s an abstracted version of storage, of a place to store stuff. The challenge is that people don’t recognize that where they are storing it is completely unsecured and it’s completely open.

Being able to say, wait a minute, this is sensitive data is step one. Step two is, how secure is it? Well, it’s sitting on a server that is wide open to the entire universe. OK, that’s a problem. How active is it? Nobody has actually accessed it since the Reagan administration, so we are OK. Actually no, there have been 10,000 hits on it from foreign countries in the last 15 minutes, so it’s a problem. 

It’s not just a matter of knowing that it’s sensitive data, it’s knowing the level of access to the sensitive data and the level of activity around it. You combine those three things together to create a pretty good heat map that would say, I need to shut this down or I have a challenge or issue here. If I can reduce the threat surface and I have fewer locations where sensitive data lives, it gets a heck of a lot easier to manage it.

We had less impact than I expected from GDPR, which could have changed how we think about storing, securing, and using data, especially consumer data. Will we see further effects from GDPR or other legislation?

You see it in California already for sure with CCPA and CPRA. You have the New York Shield Act and 32 other states that are actively debating privacy legislation. With the election behind us now, there’s definitely privacy legislation that’s at a Congressional level as well. So you absolutely will, it will continue to shift. Even CCPA has changed three times since it went into effect last year. It will continue to shift and morph because privacy is fluid.

The wrong lens to look through is, how big have the fines been for GDPR? Well, there’s been some massive ones. How many have been collected on how many have made it through the courts? We’re waiting to go ahead and see.

You have to take a step back and say, what’s the right level of stuff to do from a privacy standpoint? If you show that you are trying to proactively get ahead of the problem, then more often than not, you’re going to be in pretty good stead with the regulators. It’s not trying to keep up with the regulations, but more trying to keep up with the culture, and that usually takes a rethinking of how you move and store data. That wake-up call doesn’t typically come until there’s a breach or something bad that could happen to you that you saw happen to the healthcare organization across town.

Are health systems funding and completing projects related to security, privacy, and data protection?

They are absolutely taking it more seriously. We’ve seen an uptick, even during these crazy times, over the last six months in healthcare because they recognize that it’s a journey that they have to start. They don’t a panacea button that it solves all their issues, but they start saying that they have to get the right processes in place and the right underpinning tools in place to start getting ahead of this problem.

Most healthcare organizations didn’t pop up overnight. They have been around for 50, 100, or 150 years. If you think about the technological age, every healthcare organization that I’ve walked into has equipment and systems that go back to the time the first building was built, that date all the way to the time the most recent building was built. They have a little bit of everything, and across that little bit of everything lies a lot of complexity. For a while, the answer was, we’re just going to throw our hands up because this is too hard to get our heads wrapped around. Now it has shifted into, we have to start somewhere, so let’s put a stake in the ground and let’s start pulling the thread through it.

It’s a hard problem, especially in healthcare. Healthcare is different. A lot of it is because there’s a lot of legacy systems with a lot of legacy information that’s really, really important, but that weren’t designed to protect data the way it’s expected to be protected today.

How do you see that situation changing over the next 3-5 years?

The concept of data and sensitive data is at the core of both security and privacy. The next thing that goes around that is, what is the definition of sensitive as it pertains to privacy? Then also, what is the definition of identity as it pertains to security? I think that recognition is starting to happen, where people say, it’s not a matter of if I’m going to be breached, it’s a matter of when. The perimeter is not going to hold, so when they get in, what are they going to be able to do, and what are they going to be able to find? That gets back to the data part of the question.

People are starting to move in the right direction. They are starting to say, I need to get a handle on my sensitive data footprint so I know what the threat surface is. Then when I am compromised, I know what has happened or is happening and I can minimize the risk. I think you’ll continue to see over the next 3-5 years more and more efforts with a data-centric look at the overall infrastructure and security. That will spawn privacy. You cannot have privacy without security, but you can have security without privacy. We are already seeing that in how people are talking and thinking about how they are leveraging systems. It’s getting more and more prevalent.

Do you have any final thoughts?

When it comes to security and privacy and all the drama and all the noise that you hear about it and read about it, just boil it down to this — am I doing everything I can today to protect what matters most to the constituents I serve? And what matters most to them is their individuality. Recognizing that you hold the digital versions of those physical selves and treating those digital versions as you would treat the physical one is just as important, so make it personal.

HIStalk Interviews William Febbo, CEO, OptimizeRx

William J. “Will” Febbo is CEO of OptimizeRx of Rochester, MI.

Tell me about yourself and the company.

I’ve been the CEO and director of OptimizeRx for the last five years. I have 20 years experience in health technology. More specifically, I always find myself drawn to the challenge of connecting the life science industry with healthcare providers like doctors, both clinically and commercially. I focus on technology, data, and compliance as the key drivers.

OptimizeRx is a digital health platform that focuses on bringing adherence and affordability solutions to healthcare providers, patients, and the life science industry. We are publicly listed on the Nasdaq.

What are the ethical considerations involved with presenting sponsored product information to physicians within their EHR workflows?

We are highly focused on that. Our goal is to help drive positive patient outcomes by supporting patient affordability and overall adherence to doctor-recommended treatment plans. The doctor is driving the bus here, and anything we do is going to be triggered by activity the doctor is doing.

The market is fragmented. Doctors use electronic health records from many companies and spend hours a day on them. The last things we would want to do is add more clicks and distraction that would slow down their day and or bring content that’s just not relevant to that point-of-care experience.

We have a strong filter. Our partners have a strong filter. When you are trying to help patients and doctors with affordability and adherence, it’s really about connecting at the right time with the right people. There are certainly rules that apply. Compliance is a big piece for me when you’re trying to help in this arena. We understand that incredibly well, as do our EHRs who manage all the data. We have several filters layered in there, plus laws, and we respect them all greatly. We are helping the doctor prescribe what they want, then helping the patient afford that based on the insurance they have.

The other piece of the equation is that once people have their medication, how do you help them stay on it? We’re a big believer in SMS text as a way to stay connected to the patient once they have double opted in on that. We see compelling results when they make that choice. They are always given the flexibility to not engage or to stop being engaged.

How do you decide the best opportunities to pursue now that you have created the network and are engaging participants in it?

We have a team that has a lot of depth in terms of the life science industry, as well as the technology around networks. We focus on is the patient journey, the care journey, that we’ve all experienced personally. It sounds like industry talk, but you feel something, you go to the doctor in various settings, you’re then in the system through diagnosis and prescription, and then you pick up medication or have it delivered. We focus on the pain points for our clients, the doctors, and the patients along that journey. If we don’t meet those three criteria, we just don’t do it. 

This is not a pure advertising model. This is a model where the life science industry can bring messages — mostly clinical in nature, mostly unbranded — and give the doctor some information at a time when they’re thinking about a particular disease or therapeutic area. Then as the patient is leaving that setting, we want to be able to stay with them and help them understand and afford the medication treatment and to have the support be there. It’s through a mobile device and chatbot, which sounds like it isn’t real, but it’s better than being alone and often that additional support is what keeps people on the therapy the doctor has selected.

How do you connect your innovation lab to the folks who assess market need?

The innovation lab is really exciting. We partner with our channel partners, which can be an EHR, someone at point of dispense and retail pharmacy, or someone who does digital appointment scheduling. We focus in on those pain points. 

What has been exciting over the last few years for all of us — not just OptimizeRx, but other people in this space — is that we have both sides of the equation, the clients who can finance it and the users, providers and patients who are engaged and open to using these new methods of connectivity.

When I came in about five years ago, this company had one solution, which was focused on basically digitizing the co-pay and getting that to the doctor so they could enable it for a prescription after selection and help the patient. When we looked at all that, and we looked at our partners, we saw that there were just so many other solutions that we could bring that could address a pain point for the client, the physician, the patient, or all three. We focus on those at the innovation lab. 

We have in the recent past rolled out a hub-enrollment forms, which is in-workflow digitized, which is a pain point for physicians, anyone in the administrative side within a physician’s office, and the patient. It simplifies the paperwork process and the signatures required to process hub enrollment for a specialty medication.

We’ve also rolled out something called TelaRep. This came out of the disruption that the life science industry saw with their sales reps. Physicians can, within the workflow of the EHR, reach out to a sales representative with a question. They can do that by text or email, saying give me a call or they can do it actually through a telehealth type of video type interaction. We are really proud of that one because it, first of all, we had the technology, so we went to the innovative lab partners and said, look what we can do. Pharma had a real challenge with reps being at home, but doctors still have questions. If you look at the number of questions doctors had that went through the MyViva program and others, it’s exponentially higher. It showed that reps answer a lot of questions for doctors, around dosage, mostly. 

Those are two examples of solutions that came out of the innovation lab, where we’re close to the partners. We could talk to the clients and we could launch them all within six months, which we are very proud of.

What motivates EHR vendors to give you access to their workflows?

They are focused on their members. Helping doctors deliver care. Having the right tools to do that, to effectively try to spend less time on the EHR and more time with the patient. When we bring solutions like TelaRep and hub enrollment, it’s clear that that’s a tool for the doctor. That’s a pain point.

The other things that doctors have highlighted to the EHR partners is financial burden and any way you can bring those costs down. Patient education is another one. Prior authorization is another pain point that companies like CoverMyMeds address. We focus in on those pain points, and our partners know those pain points even more than we do because they hear from their members, the physicians. It’s a good filter test to not bring things that wouldn’t work for the doctor.

How has the pandemic changed the use of your product?

The life science industry has billions of dollars set aside for co-pay programs. We saw an increase in demand and awareness for that given the disruption in the economy for people. We also focus on specialty medications more than the gen meds, and while gen med certainly dropped because office visits dropped, you can’t go off specialty medications. You really have to stay on them. 

We saw our partners who didn’t have telehealth solutions immediately adopt it any way they could just so that they could keep a sidecar to the EHR, keep that connectivity going. We were impressed with how that was handled by everybody, because that’s a behavioral shift. Adoption rates were relatively low around telehealth and they went immediately high because they had to. The good news for everybody — patients, doctors, industry, and our EHR partners – since it is an efficiency all around. It should save time and money and keep care going through times of disruption.

Are you receiving inquiries about how your platform could help with distribution of a potential coronavirus vaccine?

When this pandemic hit in February for all of us here in the States, we as a team obviously immediately went to no travel and stay at home, like everybody. But we said, let’s make our technology available for doctors and patients for CDC alerts. Let’s just do that. Let’s not charge anything, let’s just do it for free. That’s our way of helping in a small way and it felt really good.

We immediately put those CDC alerts into the workflow for our partners. Doctors were able to see them. We allowed patients to set up an SMS text program for free, which is still active. I view the short term in a similar format. We have an opportunity to help our clients get to those targeted populations of patients that are going to be needing to take the vaccine first.

This is not going to be a rollout for everyone to take it. The CDC will segment the market, find those in need, and go to there first. We think we have a great position to help our clients through that network and we stand ready to do it. Some of those conversations are starting. Obviously we all were thrilled to see the news from Pfizer this week. I think we’ll see others, but there’s still a lot of logistics between today and when they would need to communicate to the HCPs.

This week’s earnings call had a lot of enthusiasm and momentum that struck me as being more genuine that I sometimes hear. You’ve made a couple of key acquisitions, are using your innovation lab, and your product is doing well. Where do you want to take the company in the next several years?

We are small enough to be incredibly sincere. As you get bigger, it does get a little harder, but culture is big and we’re all in it to help outcomes and build a business.

We cited a McKinsey study that found that nearly 70% of US consumers use an online channel to manage health and wellness. Over 50% of US healthcare providers are digital omnivores who use three or more connected device professionally. I think of the network that we have already created and how we are expanding into retail and devices connected to medical professionals and patients. 

I see us as becoming a preferred digital communication platform for life sciences, principally patients and doctors, while being focused on affordability, adherence, and a little bit of care management. We are very fired up to get this kind of behavioral shift, which a lot of marketing dollars can’t even buy. Something has to push the shift.

I’ve been in the industry for 20 years and pharma is incredibly innovative clinically, but cautious commercially. We are at a stage where a lot of the digital solutions combine data-driven insights, compliance, and transparency, and those are matching nicely with the devices we all carry and use and our expectations for them. We do our banking. We do our shopping. Why wouldn’t we manage our health there? It makes for an exciting next three to five years as we try to reach more physicians, reach more patients, and help our clients drive outcomes.

HIStalk Interviews Carm Huntress, CEO, RxRevu

Carm Huntress is CEO of RxRevu of Denver, CO.

Tell me about yourself and the company.

I started RxRevu about eight years ago. I have about 20 years of early-stage startup experience. RxRevu is my first endeavor into the healthcare or digital healthcare space. 

The company has been focused mainly on drug cost transparency to providers for most of its history. It’s an exciting space and a lot is happening, both with our customers and even at a regulatory level.

What outcomes can result when a patient arrives at the pharmacy where their prescription was sent electronically and they’re told it will cost $200 instead of the $15 they expected?

When you look at the data, it’s pretty interesting. About one-third to two-thirds of prescription abandonment, depending on the studies that you look at, is due to cost. That’s only getting worse now with consumer-driven healthcare.

When you think about adherence, when you think about getting the patients on the medications and keeping them on the medications that are so important in terms of driving positive outcomes, cost is the biggest thing. A lot of the work we do is focused on preventing that sticker shock at the pharmacy, which leads to abandonment and the patient not taking their medication.

It’s harder to be a savvy consumer with electronic prescribing since you have to choose the pharmacy upfront without knowing the prescription’s cost, then extra work is required to send it to a different pharmacy that perhaps has a better deal. How does your system improve that situation?

We identify that as a major issue today. If the prescription is already gone to the pharmacy, the consumer really doesn’t have much choice. What we realized is there’s this point of shared decision-making at the point of care between the provider and the patient before the script is sent to the pharmacy. That’s a really important point as they are making that decision.

RxRevu works directly with the payers, pharmacy benefit managers, and insurance companies to bring real-time cost transparency to that point of prescription, that point of shared decision-making between the provider and the patient. As the provider is prescribing, we’ll show the cost of that drug at the preferred pharmacy of the patient. We will show lower-cost therapeutic alternatives.

We will also show drugs that have less administrative overhead, both for the provider and the patient, in terms of time to therapy, such as a drug that requires prior authorization that will take time, but there’s a preferred therapy from the patient’s insurance company or PBM that does not require a prior auth. The provider can simply select that and route the prescription to the patient’s pharmacy.

The last thing we do is show alternative pharmacies. Maybe it’s mail order, or there’s a better opportunity for the patient to save money just by going to a different pharmacy in their network. We will show that as well. 

Our goal is to bring that individual patient cost transparency around their drugs to the provider at the point of care, so both the provider and the patient can make the most informed prescription decision.

Does it benefit the prescriber as well since they can not only prescribe the most cost-effective therapy, but also avoid the extra work of issuing a second prescription or sending the original one to a different pharmacy at the patient’s request?

We are, so far, one of the rare tool that providers really like. Out of all the surveying we do, we get very high marks on, “This is really valuable information that I’ve been looking for.” There’s been a lot of distrust, when this information was static and not real time, and now we can provide it real time on a patient individual basis. The number one reason coming back from providers is that while it takes maybe a few more seconds to look at the cost information and make a better-informed decision, reducing the headache of pharmacy callbacks and patient friction in getting them on therapy and keep them on therapy is a huge benefit to providers.

That saved time means a lot for them and their clinical staff. Statistics show that it costs about $15,000 per year for a doctor or their clinical staff to manage prescription administration, such as prior auths, pharmacy callbacks, and those types of things. It’s a pretty costly administrative thing. We are trying to cut that off by getting this information front of the doctor upfront so that all these issues that we’ve talked about have been sorted out prior to the patient getting to the pharmacy to pick up the script.

What were the integration challenges involved with collecting real-time information from insurance companies and pharmacies and then inserting it into the EHR workflow so that it is actionable?

It’s a challenging two-sided market, and very hard to set up. On one side, you have to set up the direct connectivity between us and the PBMs, the pharmacy benefit managers, to bring real-time cost transparency into our network. There’s many of those that we have to connect to. We’ve connected so far to about 150 million insured Americans and our network continues to grow. Our hope is that eventually we’ll have complete coverage in the US, and there’s some good things coming, from a regulatory standpoint, that will help us achieve that.

On the flip side, once you aggregate all that data, you have normalize it and standardize it so you can provide it to the electronic health records. Today we are partnered with Epic, Cerner, and Athenahealth, which arguably are the biggest ambulatory providers in the US. It’s integrated directly into the electronic health record and the prescribing workflows. That’s a big challenge in terms of making sure that the integration is done well and is part of the workflow.

We have focused heavily on the prescriber experience and making sure that it’s really in line with what they are doing today. If the doctor has to go out to a portal or another service, they don’t use it. They won’t take the time. We wanted to ensure that this is part of their workflow, so that as they are ordering the prescription, they can see this cost transparency information.

It’s occasionally cheaper for the patient to pay cash instead of using insurance, especially if they have a discount coupon. Can you detect those situations where they will pay less by not using their insurance?

We look at all sorts of discount cards, things like GoodRx. What we found in our research is those discount cards are only beneficial about 5% of the time compared to a patient’s co-pay. There are certain situations where the drug is not covered, or other situations where a discount card may be beneficial, but the truth is that while insurance is getting more expensive and co-pays are going up, it’s most beneficial to get on whatever their insurance is. Where there are cost-saving opportunities, there’s usually a therapeutic alternative or lower-cost preferred drug in the same class that would be significant in terms of savings to the patient. They’re just unaware of that, and so is the provider, and that is the information we are providing. That can lead to significant savings to the patient.

Who pays for your service?

Whoever the risk-bearing entity is that covers the pharmaceutical costs. In this case, most of the PBMs and payers we work with cover the cost. We offer this free to providers across our entire footprint. A provider using Epic, Cerner, or Athenahealth doesn’t  get charged for this and it’s part of their workflow. We want to save money for the patient and the insurance company.

How does a physician or group connect?

A small practice might be running Athenahealth, which is a cloud-based EHR, so we are automatically turned on. The providers don’t have to do anything,. We are enterprise deployed across the entire Athena footprint.

In the case of where the health system is running an on-prem instance of the EHR, which has happened a lot more in Epic, we have to come in and do about 10 hours of work to install our network into the electronic health record. It’s not too much overhead and is pretty easy to do compared to the value you get from turning us on.

What role do you see for the federal government in prescription pricing and transparency?

There is now a 2021 Part D mandate to require cost transparency for payers and PBMs that support that market. That has been huge in growing our network as more PBMs provide this as a service. We think those mandates will expand and potentially lead to provider mandates, where they will be required to have this information available to them in the EHR over the next few years.

Our hope is that this will drive a bigger discussion about cost transparency across all services, so that just like any other shopping experience that we have in our life where we know the price upfront, we can get that for prescriptions, but all services. We are one of the leading indicators of the value of this because our payer and PBM partners are seeing significant ROI in terms of cost savings to both them and their members, as well as reduction in administrative overhead in terms of prior auth and other administrative things they face with prescription drugs.

Why did so many large health systems invest in your Series A funding round?

I think there’s a couple of reasons. The first is their identification of the administrative burden and time that their providers spend managing prescriptions and the benefit they saw in having cost transparency at the point of care.

Secondly, this is helping them move into value. If you think about the push in healthcare towards value-based arrangements –ACO, fully capitated, or shared savings — prescriptions are a critical part of that success. If they have to take prescription drug risk, this type of service, in terms of having cost transparency, is critical.

Also, because cost and adherence are so tied, they want to make sure they get the patient on a drug they can afford, because that is the biggest thing that drives outcomes and prevent things like readmissions.

That was a lot of the driving force behind health system interest in working with us and having this type of technology embedded in their health systems as they move to risk and to better manage their labor costs.

Where do you see the prescription transparency movement as well as your company moving in the next few years?

We will see a pretty broad expansion of cost transparency services across all payers. I think it’s obvious that we can’t really measure value unless we know what things cost. We have proved, at least in the prescription drug space, that having this information leads to better-informed decision-making by providers and saves significant money to the payers and PBMs. The cost transparency movement is here, it’s here to stay, and it is only going to expand.

We are focused on helping providers make the most clinically effective decision that is both cost-effective and convenient for the patient. We are going to help providers, as well as patients, get that most cost-effective drug. We will support health systems as they move into value more aggressively and take on risk to optimize costs, especially around prescription drugs. Our fundamental belief is that the whole prescription drug value chain should be based on value and the outcomes that these drugs deliver to the patients who take them.

HIStalk Interviews Cary Breese, CEO, NowRx

Cary Breese is co-founder and CEO NowRx of Mountain View, CA.

Tell me about yourself and the company.

I’ve done a few startups in my life, insurance and database. I’ve always had an automation focus, using technology to automate things in legacy industries.

I started NowRx in 2016 with an idea of making the pharmacy experience better. The real question that always intrigued us when we thought of the idea was, how do you make it profitable? That’s where the technology comes into play. We believe that if you can focus and optimize all the operations, software, robotics, and logistics, you can create a profitable model that’s a full replacement for a Walgreens and CVS experience. That has been the goal, and we think we have created it. We have since expanded from the Bay Area into Orange County, south of LA, and Phoenix, Arizona.

How do you think chain drugstores have failed to meet consumer needs?

The dirty little secret in the retail pharmacy world — and I think there’s enough evidence there – is that they want consumers to continue to come into their stores. That has been their model for decades. That creates a disincentive with where consumers are moving. They are looking for more and more convenience. I can get a car to come pick me up in two minutes and take me wherever I want. I can get my groceries delivered. I can get my lunch delivered. But the retail pharmacies don’t like that model. They want to have you come into a store for an in-store pickup.

They keep the pharmacy operation itself in the back of the store. They fill 15,000 square feet of space with all other products under the sun, and that’s where the majority of their profits come from. There’s a misaligned incentive. It has been exacerbated even more during COVID, where customers and patients are realizing there’s got to be a better way than going to stand in line for essentially a commodity product at a crowded store and risk exposure to COVID.

We work with some hospitals as well. Since we’re delivering prescriptions all day long anyway, we deliver right to patients on the day of the discharge.They get all their outpatient medication delivered to their room before they go home. We can reduce readmissions and hospitalizations. We think we’ve moved the needle on medication adherence and better patient outcomes through better prescription management. People are less inclined to not take their medications because they didn’t go to the pharmacy, they were too busy, they didn’t have time. Maybe they lack access to transportation. Maybe they just forgot. We resolve all of those issues right out of the gate. Plus we have some patient analytics that we’re layering on top of that as well to do pharmacy-based interventions to target chronically ill patients and try to make a more convenient and more reliable refill and just medication-adherence procedures.

Walgreens and CVS deliver through third-party services, and mail order pharmacies, including Amazon’s PillPack, deliver to the patient’s door. Why is it an improvement to have a physical, licensed pharmacy doing its own delivery?

Mail delivery pharmacy has been around for decades. We’re not too interested in that space. We think that works well for certain patients. Chronic meds are not urgent, and the 90-day fill can be a convenience.

But if you notice, mail delivery has been around for 20 years, as in Express Scripts and Caremark, but it hasn’t made a huge dent in retail pharmacy. Retail pharmacy is still the preferred model for many customers, particularly for medications that don’t necessarily fit a mail order delivery, like antibiotics that you need today, pain medications, or when your doctor changes the medication dosage and you need to get it refilled. All of those needs exist today and are a big pain point for customers. We believe that the right model is neither retail, which requires a patient to come into a store, or mail delivery. We see there’s a optimal model in between those two that picks the best of both worlds.

We use DEA-licensed pharmacy facilities. We call them micro fulfillment facilities. They are like the operation of the pharmacy inside Walgreens or CVS, but just the pharmacy part in the back. We take that out and put in a warehouse. We put it local to customers in their communities, within 10 or 15 miles of any patient that we serve. We do all the same things that a full-service pharmacy would do. We have pharmacist consultations over the phone, text, or video chat. We have technicians. We have our own inventory in those micro fulfillment centers. Everything is delivered right to the patient same day.

For a patient, they get the same-day service they would get from a regular pharmacy. We can do all the chronic meds and refills that a normal mail order pharmacy would do as well. We can do all of that and bring it right to your house, free of charge. You just pay your normal co-pay.

Inside the pharmacy, we take the best out of the mail-order pharmacies — the technology, the automation, the robotics, and all of that streamlined software. We built our own pharmacy management systems. We’ve been awarded the White Coat Award by Surescripts as one of the most accurate pharmacy management systems in the industry. Through that automation and our logistics, we believe that we can build a better solution for patients, taking the best of the other two models that are available.

How is chain drug store technology inadequate and how have you improved it?

I’d like to say that there’s more to fixing retail pharmacy than just adding delivery. That’s one of the problems we see, which is adding a third-party delivery service. You mentioned using Instacart or some other third-party delivery company. It doesn’t really fix the bottlenecks that are inside retail pharmacy, which we think are the key.

You have someone counting out pills, typically manually in a CVS or Walgreens. You also typically have a fairly antiquated software system that gets errors from insurance companies. Patients usually have to stand on line. There’s someone behind the counter on the phone waiting for 20 minutes to talk to the insurance company about how to resolve the claim. You can manage all of that with software.

Our software also connects with physician offices electronically. We have two-way communication. We get electronic prescriptions in, but we can also coordinate refill orders going back out. We also coordinate with the insurance companies. Then we have our own logistics.

Fixing those bottlenecks can make this a much more efficient process. The mail order pharmacies are  super high volume. They have far less labor costs per prescription because they’ve been able to automate. You don’t see that kind of automation in a CVS or Walgreens, so they don’t have enough money to spend on good customer service. They’re spending it all on all those manual processes and bottlenecks. That’s how we think we can fix the industry.

I assume that you would like NowRx to be valued as a technology company, but even with a closed-door pharmacy in individual communities, you still have to get a state license and hire pharmacists. How can you scale given the limitation of opening up individual, almost neighborhood-level pharmacies?

The key is the “almost.” It’s almost neighborhood-level, but it’s actually quite a much smaller footprint than a CVS or Walgreens that are, let’s face it, just about every two or three miles. I think Walgreens claims to be within five miles of every man, woman, and child in the US. 

We have far, far lower footprints than that. We have about one-twentieth of the required footprint compared to a CVS or Walgreens. We cover a much bigger territory per one of our micro fulfillment centers. A 15-mile radius is about 10 or 12 times the radius of a typical CVS, which only draws about a mile and a half or two mile radius. Each of our locations is a third the size. We don’t need 15,000 square feet of retail space, we need about 5,000 square feet. We don’t pay as much per square foot. We pay about a third the cost per square foot because we’re in commercial space, not retail.

Add that all up — about one-twentieth the number of locations and each one is one-third the size and one-third the price – and you’re getting pretty close to 1% of the fixed overhead that the big guys play. That’s additional savings for us that drops rates to the bottom line.

I assume that the chains stuff their stores between the front door and the prescription counter with all those products because the margin on them is high. Can you make enough money from just selling prescriptions?

They do have more margin on those products. A typical CVS makes about 60% of their profit from the front of the store, but they’re paying a big cost for that. The fixed overhead is very costly in the retail setting to have all of that product. That’s why they want people in the store. That’s why their whole model is there. They have that retail space. It’s an upsell model. They want the impulse buys. They put the pharmacy in back to try to attract customers.

We sell a list of about 250 non-prescription related items. It’s much easier for me to warehouse that product. I don’t need fancy retail shelving. I can just stack it in my warehouse. We get the customer the same convenience they would have by having additional add-on items like vitamins, probiotics, cough remedies, or pain remedies, whatever they would need to add on to their pharmacies. We don’t add so many products like back-to-school supplies or beauty aids, or I even saw tennis balls at my local CVS. We don’t go down that path. But vitamins, pain relievers, cough remedies, and things like that, we do offer today. It is a higher profit margin business, and it’s very easy for us to keep in the warehouse and add into a bag that’s heading out for delivery.

Telehealth has a last-mile problem where the online visit still requires a trip to the drugstore or lab. Can that be improved?

I couldn’t agree with you more. We’ve always been big believers in telehealth. The stat I like to use is that 70% of physician appointments result in or involve a prescription medication. You are exactly right — it’s kind of ridiculous to expect a patient to have an online meeting with their physician and then be expected to get out of their pajamas and go down to CVS. We think we’re a critical component to the telehealth movement, which will is going more and more mainstream now because of COVID. We are really excited about that.

In fact, we have some additional technology offerings that are going to dovetail right in with the telehealth platform, including feedback to physicians in a portal that gives them real-time updates on the prescriptions and if they have been delivered. Did they hit the insurance plan, or does it hit a prior authorization? Do we need to do an alternate prescription? We coordinate with that physician. Then you start to have a powerful combination of collaboration between the physician, patient, and pharmacy to drive better care.

I think of all these third-party delivery services driving around to individual houses bringing groceries, takeout food, and prescriptions. An individual business, like a restaurant, might work with several of those services. There seems to be a lot of inefficiency in making multiple trips to the same front doors. Could there be a point where someone creates a Post Office-like network that does white-label delivery from any company that wants to hire them as a courier?

It’s theoretically possible, but pharmacy is so complex. There are regulatory concerns. There are patient privacy concerns.

We always felt like from the very beginning – and we’ve been even more strong in our beliefs as we’ve moved along the last few years — that the best way for this industry to provide this kind of customer experience where you’re fully remote and everything is delivered is to own the delivery stack yourself. You have your own employees of the pharmacy that are the drivers. We can background check them. We can drug test them. We check their driving. They’re branded NowRx. They wear the NowRx shirts. They are in branded cars.

The patients get a level of comfort seeing the drivers pull up. Many of these patients that are on recurring medications see the same driver month-in and month-out. They’re on the same routes. There’s no privacy issues as far as coordinating refills and who owns the patient file that you would run into with a third-party delivery service. We handle narcotics, so we deliver all kinds of medications, including Schedule II narcotics. That’s very difficult to do if you’re a third-party delivery company and trying to make that work. We’ve always come down on the side of, let’s make the best customer experience that we possibly can, make it as seamless as possible, and make it as a complete of a service as we can. To do that, you’ve got to own your own drivers.

Chain drugstores have tried multiple concepts to get more sales per square foot out of their physical footprint, sometimes launching their own services and sometimes contracting them out, such as with urgent care and lab access centers. How will that play out over the next few years?

Our original hypothesis about this space is right. The big chains are going to keep doubling down and try to make a retail model work. They have too much invested in all that retail space.

You look at the recent announcement about a month ago. Walgreens acquired a company called VillageMD, which adds clinic services inside the retail stores. Exactly what you’re saying. That confirms my hypothesis that they are going to continue to double down. They are adding reasons to bring customers into a store, and customers are looking for fewer reasons to go into the store, so there’s a misalignment there. 

In four or five years, you’re going to continue to see displacement of customers out of the retail, traditional brick-and-mortar model into these other modes. At some point, there is going to be a significant disruption. You touched on Amazon earlier — they might be a trigger point if they try to make a move. Right now, they’re doing mail order, but at some point, they’re going to try to move to a two-day delivery for pharmacy or maybe even a one-day delivery. That will put so much heat on the retail pharmacies that they will have to have a real heart-to-heart meeting with themselves to figure out how they can change their model to survive. 

Frankly, I don’t think the existing retail model will survive more than four or five years. I think consumers are going to pull away from the retail model. They want free, same-day and even same-hour delivery, and that’s where we’re going to end up.

HIStalk Interviews Paul Ricci, CEO, SOC Telemed

Paul Ricci is interim chairman and CEO of SOC Telemed of Reston, VA.

Tell me about yourself and the company.

I’ve been the chairman and CEO of SOC for about six months. Before that, I was the chairman and CEO of Nuance for about two decades. What brought me to SOC was the opportunity to accelerate the participation of the company in the exciting area of telemedicine and virtual care.

Telehealth usage skyrocketed, then tapered back off. What is driving its adoption?

COVID was an accelerant to a trend that was already underway, which was to take advantage of the efficiencies that virtual care and telemedicine offer for ensuring that we are matching patients with the best available healthcare that they can receive, independent of geographic proximity. We are focused on that in the acute setting, but it applies more broadly than that in the ambulatory, post-acute, and home settings as well.

What are the technology implications?

We serve the acute telemedicine market, so the consultations are taking place under high-acuity situations, such as a stroke victim in the emergency room or an emergency psychiatric visit. These tend to be high-acuity events. There needs to be a telemedicine specialist available with high predictability and with the requisite skills necessary to manage the consultation and provide quality care. In the case of a stroke victim in neurology, you would need to have a stroke neurologist specialist available.

The technology that is required to do that efficiently must rapidly access an appropriate specialist who is licensed in the state, privileged at the particular hospital, and with the requisite skills. That specialist has to be made available within a few minutes, with a high degree of confidence. The software and operational requirements to do that are quite demanding. It’s not really about the video link. The video link is the enabling transport mechanism for information. But it’s really about the software that fractionalizes and makes physicians available efficiently under these high-stress conditions.

Is it easier to address licensure issues since you serve specific clients in their specific locations?

You do have to address the problem of the appropriate licenses and privileging before the service goes live. But that is a significant challenge, and doing it 50 states compounds that problem. Building this kind of business at national scale is a complex operational task. That’s part of the value that we deliver to the hospitals we serve.

We’re starting to see telehealth services differentiate themselves, some offering clinical expertise and others just a platform, while some focus on remote monitoring or ongoing behavioral services versus low-urgency, episodic encounters. Are health systems offering new services through your services or are they augmenting what they were already doing?

There will be a heterogeneity of outcomes to the question you’re asking. Some hospitals will want significant coverage from a telemedicine solution, perhaps in entirely covering particular shifts or times. Other hospitals will want simply peak load support augmentation in addition to the existing resources they have, which might be their own resources or a third-party physician network. That mixture will evolve over time for a variety of reasons having to do with unpredicted scarcity, retirements, and peak demands that might occur because of prevailing illnesses. 

For us, we have built our business to be fluid with respect to that. Our software platform is agnostic to the source of the physicians, whether it’s our telespecialists, the hospital’s telespecialists, or the telespecialists they have contracted from someone else. Our platform is agnostic to that and meant to optimize under those heterogeneous circumstances.

How does the telepsychiatry service work with health system emergency departments?

Emergency rooms and hospital systems become backed up with patients who require psychiatric attention. There are strict protocols about how that has to be managed, and the capabilities and expertise necessary may not be available in the emergency room and may not be available through local staffing support. The backlogs within some facilities can become quite long, more than 24 hours, for example. Using telespecialists, we can help that facility significantly reduce their backlog, which is beneficial to the patient and beneficial to the facility as well.

What expectations have investors built into the high valuation of telehealth companies?

The market is anticipating that telemedicine is going to play a more significant role and that virtual care generally is going to play a more significant role in the delivery of healthcare services. As we look ahead five, 10, or 20 years, I think that is directionally correct. These companies, including ours, are being evaluated as having a significant growth opportunities within that growing market opportunity for the virtual provisioning of healthcare services, which has a number of benefits. It eliminates geographical inefficiencies and geographical restrictions. It allows optimizing the provisioning of very expensive scarce resources. It enables more data and analytics behind the delivery of the service, which over time will help to optimize service.

Can you describe the benefit of going public via a special purpose acquisition company or SPAC as SOC Telemed is doing versus the traditional IPO?

A SPAC is the merger of an operating organization, in this case SOC, into an investment company, in this case Healthcare Merger Corporation. By merging, the operating company SOC effectively ultimately goes public. That final event occurs, in our case, in a few days.

The advantages of doing that were twofold. One, the Healthcare Merger Corporation came with leadership with deep skills in the healthcare field. In particular, the CEO of Healthcare Merger Corporation, Steve Shulman, has a long history in the healthcare industry and is going to become the chairman of SOC.

It also brought a second benefit, which was that in a relatively short period of time — we announced the merger in July and will be consummating the transaction at the end of October — it allows access to capital, and SOC needed access to capital to prosecute the growth opportunities that are available for it in the market. Management expertise and capital for growth are really the advantages.

What lessons did you learn in your long career with Nuance?

There were lots of lessons over 18 years of Nuance. But the ones that in the end mattered the most were that if you have a big vision, stay focused on that vision and the mission of what that vision entails, assemble a great team, and pursue it with urgency and speed, you can get a great deal done. That’s really the story of Nuance.

We didn’t know when we started all the various avenues that would become available to us, but we worked incredibly hard. We took nothing for granted. We had a team that worked with a great deal of solidarity. We had an expansive vision about the ways in which speech and natural language could change the ways people engaged with information systems. All of that came together. We had a little luck along the way, of course, and in doing it, we affected some significant changes and built a great company with terrific associates.

Where do you see the SOC Telemed moving in the next few years?

SOC will be the leading provider of acute telemedicine services. The prediction that as much as 20 or 30% of acute healthcare can be done through virtual care and telemedicine is probably reasonable. Therefore, it’s an expansive opportunity.

The company will continue to build deep expertise in its existing specialties of neurology, psychiatry, and critical care, but it will grow and it expand into other specialties as well. It will increase the technological content of its solution, perhaps through the incorporation of more predictive analytics, incorporation of some AI capabilities, more sophisticated workflow, and integration into other aspects of clinical technology systems. All of that will continue to evolve over the next five years. SOC Telemed will be a leader and a visionary in doing that for acute settings.

Do you have any final thoughts?

The virtualization of healthcare is going to represent a significant opportunity for making healthcare more efficient and improving the quality of outcomes. SOC is proud to be a part of that because it will be a significant move toward the increased digitalization of healthcare.

HIStalk Interviews Darren Sommer, DO, CEO, Innovator Health

Darren Sommer, DO, MBA, MPH is founder and CEO of Innovator Health of Jonesboro, AR. He is also an assistant professor in the Department of Clinical Medicine at NYIT at Arkansas State University, a lieutenant colonel in the US Army Reserves, and served two combat tours in Afghanistan in Operation Enduring Freedom as brigade surgeon for the US Army’s 82nd Airborne Division, 2nd Brigade Combat Team, where he earned the Bronze Star, Combat Medic Badge, and Combat Action Badge.

Tell me about yourself and the company.

I’m an internal medicine physician. My origins in the telemedicine space came after deploying to Afghanistan in 2007. I had trained at a suburban hospital in the Tampa Bay area, but was then exposed to some unique pathologies being in a third-world country. The Army had a very good communications infrastructure that allowed me to connect with people around the world.

I used that as the foundation for thinking about how we can use telemedicine to serve and support our rural communities here in the United States. It was a glaring gap for me that the main telemedicine systems that are in existence today, and definitely those at that time, were created for another purpose and then repurposed for healthcare. It was difficult enough to have a conversation in the room with a patient about a diagnosis of cancer, HIV, or Mom’s dementia. It was almost impossible to do that with the existing technology. 

We set out to create a platform that would allow us to be at the patient’s bedside, in life-sized form, in 3D, and with direct eye contact, so that the patients felt like we were there with them. That was the origin of Innovator Health.

Now that we’ve quickly broadened experience with telehealth, how can doctors approach video visits in a way that is more acceptable to patients?

It’s funny, because if you ask 10 doctors how they define telemedicine, you’ll probably get 11 different answers. Most physicians look at telemedicine as just a two-way video conversation. Many of the health systems during COVID used basic Zoom-like technologies to connect with patients. When I talk about telemedicine, I talk about patients in a hospital environment, using medical instruments for diagnosis and treatment, access to the electronic health records, and sophisticated care delivery for telemedicine services. It’s different than how the rest of the market is looking at it.

Does clinician personality type play a role in their success in virtually connecting with their patients?

Good bedside manner is important, regardless of where you are in relation to the patient. I can be physically present in the room with a patient, not look them in the eye, not answer their questions, look at my watch, not allow them to feel at ease, all while being physically present. That’s not going to be a good experience for the patient.

On the contrary, I can be on the screen, be attentive, focus on their questions and answers, interact with their families, provide them the help they need, and have a great interaction. I’ve had many patients provide exceptional comments on the satisfaction that they’ve received from the care we’ve delivered through the telemedicine system in ways that I’ve rarely seen colleagues get in person. So I think it’s much more about how you interact with the patient as opposed to where you’re interacting from.

How do rural areas address the issues of having few doctors and limited connectivity?

My interest in the rural community is because it’s the area that has the greatest need. Look at the evolution of healthcare over the last 40 or 50 years. If I had graduated from residency in 1970 and moved to rural community, I most likely would have been able to do almost anything in that community — minor surgeries, delivering babies, primary care, and a host of things. Over the last 40 or 50 years, as we’ve evolved clinically as a profession, we’ve gone from just a few specialties to almost 100 specialties, and the ability to provide a broad range of services has become more limited. Hospitals don’t have the range of services they did 20 or 30 years ago. That means people in rural communities have to actually physically leave the local community and drive to an urban area to receive care from a specialist.

Many of these services could be provided virtually. Even take surgery as an example. You could have a preoperative visit, where the surgeon talks you to them about your case. You could make a trip into the city, let them examine you, figure out exactly what’s going on, have a follow-up visit before your surgery, have your surgery in the city, and then do post-op visits back in the local community. I look at it as a spectrum of capabilities that exist in combination.

These rural community hospitals are extraordinarily important. They are typically the largest employers. They bring in a lot of revenue. From an economic perspective, most businesses are not going to invest in putting plants or businesses in rural communities if there’s not access to healthcare for their employees.

We have about 1,500 of them across the United States. They make up about 25% of all the hospitals in the US. Without them, our healthcare would be in a worse shape than it is today. Having access to these hospitals is important. I feel like it’s our mission see what we can do to bring high-quality healthcare.

From a strategy perspective, as it relates to the low bandwidth, we understood early on that bandwidth is going to be limited regardless of where you are. There are always limits in bandwidth. It’s less of an issue in big cities and big hospitals, but if we’re going to make a difference in communities, we had to make sure that the communications interactions are going to be good. 

We focused on creating a low-bandwidth system, and the team at Metova was excellent in helping us create that. That has served us well, because as we have conversations with health systems, some outside of the geographic United States, one of their main issues in being unable to provide telemedicine services for COVID patients is limited bandwidth. That’s as much a part of what we do as the interpersonal parts.

The patient’s experience is also driven by factors that are outside the provider’s control, such as the device form factor, bandwidth, their location, and falling back on audio-only visits because of technical limitations. How can those be managed?

Anybody who is looking at setting up a telemedicine program that will serve rural communities or people in their home has to take that into account. They have to recognize that you may go into a 75-year-old widow’s home in a rural community that doesn’t have fiber broadband connection and that may have only one cell phone provider in their community. Recognize that if you really want to make a difference for that patient in that community, you’re going to have to take those things into account. Hopefully the vendor partner that they work with will help them to work through those types of ideas and thoughts. 

One of the things I noticed very early on in this industry was that there are a lot of telemedicine systems out in rural hospitals that aren’t being used. It was like a treadmill. Someone says, I want to get in shape, so I’m going to buy a treadmill. They take it home, set it up, put on their athletic clothes, and they start walking or jogging. They got hot, sweaty, and tired and they realize it was a lot more work than they thought. They fold the treadmill up, and then a year from now, it’s a clothing rack. Many hospitals have dusty telemedicine systems sitting around that have not been used since they were rolled into the room. A lot of it has to do with not being aware of some of the challenges that exist, which include bandwidth for providing these services to patients.

Why have telemedicine visit volumes dropped after lockdowns ended?

A lot of the telemedicine that was being done during the lockdowns was really just Zoom calls. They were not full-fledged telemedicine exams. I think a lot of it has to do with the fact that physicians still want to be able to not only see their patients, but be able to take vital signs, do exams, and listen to heart and lung sounds. That really wasn’t in play a whole lot during COVID. The other part of it is that there is still some lack of clarity as to the volume of visits that are being done today. I’ve seen varying numbers. 

People are still trying to learn and figure out how best to do it. They’ve made some headway in using telemedicine, but there’s still a lot of resistance. If we talked about telemedicine last year at this time, only about 25% of physicians in the United States were doing any form of telemedicine, and less than 1% of all visits in the US healthcare system done last year were done by telemedicine. So there is still a strong lack of real knowledge and understanding about how to put a program together, and what we are really saying when we say we’re doing a telemedicine visit, going back to whether it involves full diagnostic capabilities or just two people talking about their health issues.

What is your reaction to investor enthusiasm about telemedicine-related vendors?

Telemedicine was first listed in the medical literature in 1974, if I remember correctly. It has been around a lot longer than people think. Companies like Teladoc and Doctor On Demand have been able to commoditize a service that has always been available to most people. Ten years ago, if you had a family doctor and weren’t feeling well on a Friday night, you had the ability to call the office. The on-call doctor would talk to you, ask you about your symptoms, and call you in a prescription for an antibiotic. If you didn’t have a doctor, you didn’t have access to that service. 

Having a Teladoc or Doctor On Demand allows everybody to have that capability, so that when they need something, they can make that phone call. They found a way to turn that into a business, but that’s a very small percentage of all the healthcare service that we are providing today. Acute care is about 20 to 25% of the total visits being provided in the US healthcare system, and there’s only so much you can do when you’re just having a conversation with a patient about their healthcare. You can’t get vital signs. You can use the camera to look at a rash or at the back of somebody’s throat, but there’s a lot of variability in lighting, motion, and distance. 

If we’re being honest, most visits, even through those types of companies, are probably being done without the use of video. The vast majority of those are done just by having a conversation with the patient, understanding what their complaints are, and then talking about how to manage it.

Are you concerned as a physician that primary care, especially in young adults, has turned into episodic, as-needed encounters via video or urgent care centers?

The market will have to correct itself on that. People will overuse this capability, bad outcomes and customer dissatisfaction will result, and people will steer away from it or demand a better service or outcome. That will drive the change. That’s probably natural and inherent in all types of businesses and economies.

For me personally, I’ve always tried to focus on the clinical standard of care. If we can provide that through telemedicine technology, then we will, and if we can’t, then we won’t. We’re not going to do anything that won’t deliver the same level of care and service virtually that we would expect in person. Having that as a standard has served us well.

For quite a long time, we were the only physician-led telemedicine company in the country. Most all of these other companies are led by some type of executive that’s not healthcare oriented. In many companies, if you go and you look at their “about us” page, even in the telemedicine space, you’ll scroll down quite a way until you find an actual physician on their leadership team. That has a big part of the problem that we’re seeing

I was struck by a statement you made to an interviewer in which you said, “”In the Airborne, they drop you in behind enemy lines and you find a way to succeed or you expect to die.” How does the Army select or train soldiers who can succeed in that paradigm, and how has that influenced how you practice medicine and business?

The Airborne has evolved since its founding right before World War II. It created a legacy for itself about who and what they did that has extended through generations. Not everybody who’s in has the same mindset, and sometimes somebody is assigned to a unit who may not want to be there. But for the most part, the esprit de corps that exists within the 82nd Airborne Division is of the mindset that they understand that that’s their mission. Either you go in behind enemy lines and you succeed , or you face death. Having that experience and having the opportunity to work with warriors that have that same mindset changes the way that you focus and look at managing problems.

Now in my life, failure is not really an option. I focus on what the mission at hand is, and then any way that I need to go about it to succeed. Starting a company six years ago … you hear the stories of how hard it is and how challenging it is. I don’t think there’s any way to help anybody understand what that really means, because it’s a personal journey, but it is one of the hardest things I’ve ever had to do in my life. If it wasn’t for that experience and  training in that mindset, I might have given up. I’m very thankful for having the tenacity to tackle this without any thoughts of giving up.

Where do you want the company to be in the next 3-5 years?

We are not focused on gratuitous growth. We are completely privately funded. We have very deep relationships with our clients. We help them. Most of our growth has come internally from existing clients, doing a good job and then growing the company.

I still think the market is very immature. Although COVID has pushed us towards an acceptance of telemedicine, I see a lot of people still doing it incorrectly. We are in a phase right now where people are going to get the opportunity to try to do some telemedicine and they’re going to fail. They’re going to look to companies like Innovator Health to say, we hadn’t done telemedicine before COVID. We tried it during and after COVID. It hasn’t gone really well. We see the success that you’re having with a lot of these other health systems. Can you help us? We will be right where we want to be during that time to help them.

I’m quite comfortable being the biggest company that nobody’s ever heard of. Our focus is on making sure that health systems have the ability to reach out and connect with communities. We don’t want it to be about us. We want it to be about the relationship between the patient and the provider.

Do you have any final thoughts?

I appreciate the opportunity to share what we’re doing. People really don’t understand the capacity of what we have the ability to do until they actually see it. If someone says, this is interesting but I don’t think it’s right for us, then I would say they should definitely reach out and let’s talk.

From a “if I knew then what I know now” perspective about telemedicine, I always encourage people to try to do something. People talk about doing a telemedicine program, they try to set something up, then they try to do too much at once and they don’t wind up doing anything. Start a small project, learn and grow from that. You’ll see that in time, small projects will turn into something large and successful, as long as you take the leap of going out there and trying to get something done.

HIStalk Interviews Feyi Olopade Ayodele, CEO, CancerIQ

Feyi Olopade Ayodele, MBA is co-founder and CEO of CancerIQ of Chicago, IL.

Tell me about yourself and the company.

I started CancerIQ when making the transition from the world of finance into healthcare. I joined healthcare with an amazing co-founder, my mother, Dr. Funmi Olopade. She’s not only a great mom, but she’s a MacArthur Genius Award winner for her work in understanding the relationship between cancer and genes.

I was motivated to start the company after working with her at the University of Chicago and realized that her vision was for genetics to be part of routine care, but that was really only possible in some of the academic centers that have those resources. I’m all about democratizing access to what we believe is the most cutting-edge version of care. That’s why I left the University of Chicago to start CancerIQ.

To what extent can cancer be predicted using genetic profiles?

To a great extent. In fact, the first cancer gene that was identified was the BRCA gene. Despite us having known for 30 years that the BRCA gene causes breast and ovarian cancer, there has been unfortunately limited adoption of genetic testing. About 10% of patients who should be tested, even for the BRCA gene, have been tested. What’s also exciting is that they can not only understand your risks, but there are also well-defined clinical protocols that have been validated to help you reduce your risk, or eliminate that risk altogether.

Many oncology treatments aren’t pursued because of insurance or other financial issues. Does insurance cover the cost of genetic screening?

Absolutely. The insurance companies have done the math. It’s expensive to treat a patient, only to have them come back with a secondary cancer that you could have known about earlier. It’s also very expensive to treat somebody who has a predisposition and is going to get a more aggressive cancer, or get it earlier than standard cancer screening age, so payers have been willing to cover this testing.

What has held providers back is knowledge, workflow, and time. We’re solving those with CancerIQ.

What is involved in doing the screening and what kinds of providers can offer it?

Risk assessment starts off with the cheapest genetic test available, and that’s your family history. While it costs nothing to evaluate your cancer history, if you’re like me and have 31 first cousins, it could take a provider a whole lot of time. That’s one of the initial barriers that holds people back from this process. It’s time-consuming to see who meets the criteria for genetic testing, but it’s also time-consuming to fill out all the insurance paperwork to get coverage for it. 

In terms of the types of providers who can perform the screening, genetic testing was initially incurred in specialty care. Genetic counselors were given this responsibility, but unfortunately, millions of patients need this service and we have only 700 cancer genetic counselors. A number of professional societies encourage doing this kind of genetic evaluation, ranging from oncologists to OB-GYNs, who have been on the forefront of doing this in preventative care.

Can the screening be performed in a telehealth visit?

Absolutely, and that’s where we have seen the biggest traction, during COVID, when people are anxious about going in for their cancer screenings, CancerIQ is a mechanism by which providers can evaluate their patients remotely and give them peace of mind on whether or not they can afford to delay their cancer screening or determine if they must be prioritized to be screened earlier rather than later.

What would the trigger be that would suggest that an individual is a candidate for screening?

Pretty much every patient should get a CancerIQ at some point in time. What we see as the future of healthcare is being proactive and preventative. If we could know everyone’s risk by the age of 21 in the future, it could help with better, more personalized, or precision health recommendations so that people can get ahead of cancer.

Is there psychology involved in telling that 21-year-old that they are genetically predisposed to get cancer decades down the road?

I would say that 21 is probably a little early because there aren’t too many established guidelines that would change the way you’re managed at the age of 21. But that depends on your risk. If you are at an elevated risk and many people who have these predispositions will get cancer under the age of 30, then you should start some of these screenings under the age of 30. I don’t want to opine on when you should start, but what is exciting about the future of healthcare is that you could get a genetic evaluation at a certain age, and through CancerIQ, your provider can monitor and manage you over time.

An individual’s genetic makeup doesn’t change over time, but new research findings about the health implications of DNA are ongoing. How do you collect those new findings and reapply them to existing genetic profiles?

You hit the nail on the head. While your genetic data will not change, the interpretation of that data and the recommendations on how to address that predisposition will change all the time. In fact, they change almost quarterly. That’s why CancerIQ has a great, purpose-built use case alongside the EHR. At the end of the day, we are a content engine that can help interpret that information, not only for the provider, but to make sure that patient is getting the most up-to-date care.

What elements of patient engagement are involved in regularly reapplying that new knowledge to someone’s profile and then communicating any new concerns?

That’s where CancerIQ has differentiated ourselves as a solution that will manage a longitudinal relationship with the patient. We not only have provider features that provide clinical decision support, but we also have cutting edge patient engagement features that allow them to receive reminders and updates through the CancerIQ platform. Eventually we will make it so the patient can carry their CancerIQ from one place to another.

What are the typical steps in a patient journey in interacting with your system?

I’ll use the BRCA case because that’s probably the easiest for people to picture. When you check in to a provider visit from the comfort of your own home, you provide your family history. It’s a lot easier for you to recall the cancer in your family than for your provider to interview you to find it out, so we take that burden off the provider. If you are at elevated risk, we will generate some patient education for you and your provider will have a discussion about the need for genetic testing. That’s where your provider will be able to use the test platform to order testing from a number of our embedded genetic testing partners, where CancerIQ will ultimately facilitate the ordering of that test.

As I mentioned before, providers are being held back by filling out the insurance documentation paperwork. Patients who go through the CancerIQ experience are going to be working with providers who have a streamlined, easy way of making sure it’s covered by their insurance. They have peace of mind that they won’t really need to pay much out of pocket. When they get their test results back, they’ll get a personalized action plan based on their genetic testing results.

Some of those action plans could be things like getting a breast MRI in addition to a mammogram. In the COVID context, it could be that you were at the top of a priority list for someone who needs the breast cancer screening because of your level of risk and ultimately that early detection strategy isn’t something that happens once. As a patient, you’ll get a reminder every year that you need to get that breast MRI. Should the guidelines change, where they say, “Maybe we need to do one of those really cool blood detection cancer tests in the future,” CancerIQ will communicate that to the patient so that they ultimately have not only the most clinically valid options, but the best options for detecting cancer early or preventing it altogether.

Consumer DNA test results often surprise people whose blood relatives don’t necessarily match what they have believed, with unknown siblings or different parents than they were raised with. How useful is the self-reported family history compared to actually testing someone’s DNA?

The future of healthcare is going to be genome-first. Family history is what we had in place and is the earliest form of risk assessment. We of course continue to support that. But part of the real value in CancerIQ, and where we see the healthcare ecosystem heading, is that we will be able to do genetic testing on people, and we may reach to that first. But as we reach to doing the testing first, what will become more important is the interpretation of the testing, the clinical decision support, and a lot of the intelligence layers that CancerIQ offers. If you don’t know your family history, CancerIQ can still interpret that genetic data to get you the right preventative health care plan.

Most investors are older white men who, consciously or subconsciously, tend to fund startups that are led by founders who are like a younger version of themselves. How do you pitch the company for funding knowing that’s the case?

I always pitch my company in the way I know it will resonate with an investor. I started my career in finance and used to be an investor. To get over the hurdle of them looking for a younger version of themselves, I’ve always shown them data on the value of our company and the traction that we’ve made. We have demonstrated that we are extremely valuable to some of the best health systems in the country. We are data-driven in showing how we can increase their downstream revenue, detect cancer early, and even improve their cancer screening rates. I’ve always had to lead with data to overcome some of those biases. Once they see the incredible performance and traction of CancerIQ, it typically gets me to the next meeting.

What do you see happening with the company over the next 3-5 years?

I see the market growing, primarily driven by the science. We understand the correlation between cancer and our genes, but we’re also starting to learn a lot more about cardiac diseases and other chronic conditions. I see the company in the next 3-5 years meeting that need and expanding from CancerIQ to CardiacIQ and ultimately being able to support full genome-based care.

I also see this moving from something that is done only in specialty care to becoming part of a primary care visit. Decision support technologies and things that can offer artificial intelligence will be a huge part of what we do in the future.

Do you have any final thoughts?

CancerIQ is partnering with a number of the available HIT solutions. We started off point-to-point integrations to make sure that our data gets into the EHR. But we are excited, given that we are managing content and data information that changes, by FHIR interfaces and allowing the provider to feel like they are not leaving the EHR, but are still getting the benefits of CancerIQ in their workflow.

HIStalk Interviews Harjinder Sandhu, CEO, Saykara

Harjinder Sandhu, PhD is founder and CEO of Saykara of Seattle, WA.

Tell me about yourself and the company.

I’ve been working on artificial intelligence in healthcare for about 20 years, starting before it was cool to call it artificial intelligence. I transitioned from a role as a professor of computer science into entrepreneurship. A friend and I co-founded a company doing speech recognition and natural language processing in healthcare. We sold that company to Nuance Communications and I spent several years as the VP and chief technologist in Nuance’s healthcare division.

I founded Saykara a few years ago with the idea that doctors should be able to focus on seeing patients and that we can build AI systems that can capture what they say and automatically enter the pertinent data into the chart. That’s what Kara, our virtual assistant, does.

Healthcare encounters involve a complex, two-way conversation with minimal guidelines, structure, and length. What technology advances allow turning that conversation into encounter documentation whose accuracy is high enough to avoid manual cleanup afterward?

Two things. One is that we started out using a “human in the loop” model, which means that behind the AI is a person who will make sure that the system gets it right. Doctors get a good experience from Day One because the AI picks up a lot, but then humans not only help correct it, but also teach it.

The second thing we do is on the AI side. AI is advancing at a very rapid rate and our goal is to get to a solution that is purely autonomous, without any human in the loop. We are doing that by teaching our system how to recognize specific clinical pathways that are the subject of what the doctors are actually doing with their patients and start interpreting along those pathways. That helps a lot in terms of figuring out what the system should key in on at any given encounter.

How is that use of behind-the-scenes humans to correct and teach the system different from just hiring scribes?

In the short term, it may look very similar to the end user, where they get a clinical note or an order put into the EHR. In the longer term, as the system gets better and better, we can provide that same service at a much lower cost, but also go well beyond what a scribe would be able to do. Our system is learning to predict what’s happening in an encounter, to put specific nudges in front of physicians, and then along the way, we capture everything in the form of discrete data. We are able to populate and construct data in a way that is virtually impossible for people to do without a lot of effort and cost.

What does a typical patient encounter look like to a provider using your system?

There is no “one size fits all” for all providers. Different providers use the system very differently. But a typical experience would be that during the encounter, the physician turns on Kara on their IPhone app. They walk in, turn the app on to start listening, and then they just interact with their patient.

A lot of providers like doing what we call reflective summarization to make sure that the system captures the right things. They will speak, either during the encounter or afterward, to tell Kara, here are the key points that came up in this conversation or the things I did in the physical exam or in the assessment plan. They let the system key in on all of those things and make sure those are the core of what gets documented.

How does EHR integration work to get the information into the chart?

That varies a lot by EHR. Some EHRs are not geared towards capturing anything more than a blob of text as if it were from a clinical note. Others have granular APIs that allow you to take specific parts of what is being communicated and populate it, uploading diagnoses or other information that needs to go into registries. We find that the integration experience varies a lot, but we capture on our side as much detailed data as we can, then push into the EHR as much as the EHR is able to consume in the form of APIs.

What do users cite as the biggest benefit?

The biggest thing that our physicians say is that it eliminates pajama time. That’s the biggest thing that users want. Physicians are spending hours in the evenings trying to close their charts. We eliminate that almost across the board for all of our users.

Physicians like the idea that whatever they’ve done in that encounter, they can rely on the system to create very accurate rendition. Because we have humans behind the scenes helping the system and making sure it got it right, physicians get accustomed to the fact that the system creates very accurate information. They can mentally offload what they are doing and then move on to that next patient.

How long does it take from the first time a physician turns on the system until they feel that it is benefitting them?

Most of the time, it’s on the first day. A provider either types during the encounter, which draws their attention away from the patient, or they spend their evening time trying to close that chart. Their first note on the first day they start using the system will be highly accurate. Providers literally tell us, “This changed my life on Day One.” Largely because, all of a sudden, they found that they weren’t sitting there typing during that encounter or that evening they went home and they didn’t have those charts to do.

The value is very, very fast. And of course, behind the scenes, the AI is learning and getting better and more autonomous over time. That part takes time, but the immediate value for that physician is on Day One.

Having spent time at Nuance, how would you compare Kara to their ambient intelligence product?

Ultimately, we are trying to solve the same problem. The proof is what is happening behind the scenes and how intelligent the systems are getting behind the scenes, because Nuance also uses human scribes behind the scenes. We started four years ago at Saykara trying to solve the hard NLP problems to get the systems to be fully autonomous. We are on the cusp of releasing models that are going to be fully autonomous for specific pathways. The real distinctions are coming in the next little while.

Otherwise, doctors are oblivious to what happens behind the scenes. They just see a note that comes back to them.

We are training our system to do a lot more than clinical notes, such as clinical guidelines, coding, providing nudges, and predicting what is about to happen in that encounter. We are starting to put some of that in front of physicians, and you’ll start seeing those differences.

Since the clinician isn’t aware of how much of the final result was delivered by the AI or the scribe, is it the company rather than the user that will get the benefit of moving toward better-trained AI?

It’s a bit of both, actually. Certainly we benefit as the system becomes more autonomous, but there’s a huge benefit for the providers. I look forward to a point where they can see what the system is doing in real time, and we are starting to put some of those things in front of the physician. They can see guidelines and what information they need to capture during this particular encounter to cover it. Physicians are asking about those kinds of things.

The system is learning to interpret these encounters. We can teach it to figure out for the subjective part when the patient says “shoulder pain” to consider what questions the physician would typically ask a patient about shoulder pain, or the kinds of responses that a patient might give.The system is gearing up to be able to communicate directly to the patient to collective the subjective information before the encounter begins, which will offload work from the physician. Ultimately, that subjective information is really the patient’s voice, and it’s coming from them anyway.

Sometimes companies that offer a physician-targeted product struggle with creating a marketing and sales organization that can reach out to an endless number of practices to make sales. Who is your target customer and how will you reach them?

We get users across all tiers of the healthcare ecosystem, from large health systems all the way down to small group practices. I would say the sweet spot for us today is really large specialty groups. That’s where we find rapid uptake and a great deal of success. Within the large health systems, we find specific physician groups reaching out, particularly in primary care, for example, where burnout is a big issue. And then of course the small group practices.

From a marketing perspective, we’ve focused our efforts on reaching out with a message of, “We solve the problem of burnout.” A lot of the sales effort ends up being directed at the large specialty groups, but we get a lot of the health systems and the small groups coming along just because they feel that message and they want solutions for their physicians.

I appreciate your transparency in describing how humans are involved in your offering since some companies, especially those who yearn for a tech company valuation, market a proprietary black box that performs magic. Are companies trying too hard to get AI to do everything instead of accepting that it could be brought to market faster and less expensively by just shooting for 90% and letting humans lend a helping hand?

It depends on the area that AI is being applied in. When it comes to conversational AI, by which I mean listening and interpreting conversation, that’s an extraordinarily difficult AI challenge. We are making pretty substantial strides in that right now, but there are areas where you can apply AI where the AI systems can actually do a pretty good job without needing any kind of human power. But certainly in this space today, we are just at the infancy of NLP.

NLP has been around for a long time. I’ve been working on it for 20 years. But I would say just in the last year, we’ve seen so many gains just within our own system and across what’s happening in the industry outside of healthcare, even in NLP. But where I can see over the next couple of years, a lot of these solutions, our solutions, are going to be completely autonomous. But right now, that’s the right fit for this space today. For other industries, other applications of AI, it may or may not be. You  have to pick and choose the strategy used for what you’re trying to do.

Where does the technology and the company go over the next 3-5 years?

I often use the analogy of driverless vehicles. Ten years ago, people thought autonomous vehicles were a distant future, and nobody gave it much thought. Suddenly we wake up one day and there are autonomous vehicles on the road. They have drivers behind the wheels, but the vehicles are starting to drive themselves. Now you can go a pretty long distance without actually touching the wheel.

I look at AI in healthcare in that same kind of way, where we have the human in the loop. The AI is learning from what those humans behind the scenes are doing, but what is more interesting is that it is learning from what the doctors themselves are doing. If you put a camera on a doctor’s shoulder, connect it to a really intelligent system, and tell it to watch what the doctor is doing — how they’re interacting with the patient, what kinds of questions they are asking, what they do in their physical exam — and connect this to the EHR whose data the physician is using to make their decisions, you are building, over the long term, an intelligent system that can actually understand medicine. 

The scribing part of what we’re doing is just the cusp, the tip of the iceberg. The more important and more interesting trend is that, over the next 3-5 years, these systems will actually start understanding the process of providing care to patient. We will be able to supplement and assist doctors in ways that we haven’t really thought about today. That’s the part that I get excited about.

Do you have any final thoughts?

We are extremely early in the AI revolution in healthcare. Really, it hasn’t been a revolution. We are augmenting processes in healthcare, making them more efficient, and making physicians happy. Not just us, but other companies in this space. But what we’ve seen with AI technology in other industries is that it reaches an inflection point, where the AI begins evolving much faster and starts being able to do more in a short span of time than people would have imagined possible. I think we are almost at that inflection point in a lot of processes within healthcare. We will see, over the next couple of years, incredible disruption to the business of healthcare, and in a good way.

A core part of that is natural language processing.  So much of healthcare, so much of medicine, is communicated by voice. When you can do a really great job of interpreting and understanding what’s being communicated, what never actually makes it into the medical record or doesn’t make it into the medical record in a systematic, discrete way, you’re able to understand how to communicate with doctors on their own terms. Not in the way that you as a interface designer want doctors to interface with your system, but the way the doctors would naturally interact with other doctors or with a patient. You can interact with them in those terms. You can interact with patients on their own terms as well. That revolution is going to create a new platform and new capabilities that we can only start dreaming of today.

HIStalk Interviews Brent Lang, CEO, Vocera

Brent Lang, MBA is chairman and CEO of Vocera of San Jose, CA.

Tell me about yourself and the company.

I’ve been with Vocera for 19 years. I was brought in by the founders, initially as the VP of marketing back when it was just a few guys in a dark lab trying to figure out if they could make our product work. My wife used to tease me that I was the VP of business, as opposed to the VP of marketing, since I was trying to figure out our go-to-market strategy, our pricing strategy, and our target customer.

The company was not originally created as a healthcare-focused company. The founder’s vision was to enable wearable communication across multiple markets. One of my first jobs as a VP of marketing was to go out and interview a bunch of potential customers about the idea of wearable, hands-free communication. We started talking to some hospitals and nurses were so excited. I remember one hospital nurse saying to me, “You’re going to change the way nursing is practiced around the world.” At that time, I had no idea what she was talking about because I had not come from a healthcare background. I was more of a technologist, having made my way through Silicon Valley tech companies with an interest in technology and business strategy.

I fell in love with the impact that technology could have on hospitals and healthcare workflows. I was an industrial engineer back in school and never really thought about too much how I would use that until I started thinking about the role that communication can have on improving workflow and operations within a healthcare setting. I tell people all the time, just learn what you can, because you never know what knowledge you’re going to pick up along the way that will be relevant to you at some point in your future career, even though it may not seem particularly relevant at that particular moment in time.

Cell phones, apps, and phone-based texting were not around when the company was started. How have they changed the appeal or the marketing of healthcare-specific communications?

People forget that we created the company before Siri, Alexa, and the IPhone. Vocera revolutionized the idea of communication using voice as a user interface and thinking about mobility. We built the original Vocera badge because there weren’t any other appropriate devices. The closest ting might have been a Palm III, Palm V, or later, the Treo. Hands-free is critical in a hospital, so we built the device mainly because there was nothing else that would work. We have learned over the years just how essential the hands-free capability is.

We have embraced a range of different devices. Our strategy is very much about being device of choice, and our software platform supports iPhones, Android devices, tablets, and desktop interfaces. But we find that the closer a clinician is to direct frontline care, the more important it is to have that hands-free capability, and it’s even more relevant during COVID. But what has been important for us was to figure out ways to bring in those other modes of communication that you mentioned — text messaging, alerting, alarming, and other forms of media — into the platform and into the devices that we support.

The new Smart Badge recognizes a “wake word” to make everything hands-free. How important is that to clinicians?

We introduced the wake word earlier this year. You can say “OK, Vocera” to wake up the Smart Badge and allow you to issue a voice command, such as, “call the nurse for room 101” or “call a respiratory therapist.” You don’t have to have any interaction with a button on the badge at all. In this era where people are wearing personal protective equipment, or PPE, a lot of people are excited about the wake word functionality, because they are able to wear their Smart Badge underneath their gowns and maintain an entirely hands-free environment.

Could you integrate your system with inexpensive consumer voice assistants that could be placed in patient rooms, which would allow patients and nurses a simple, hands-free way to communicate, either along with or instead of a call system?

This is actually an area that we are really excited about. We are building a Vocera skill for Alexa that will allow you to put an Alexa device, like an Amazon Echo, in the patient’s room and enable the patient to issue voice commands. Those messages are then routed to the appropriate caregiver. We can leverage our software platform and routing intelligence so that we know who to notify if the patient asks for a blanket, but if the patient says that they are in pain, it can go directly to their nurse to take immediate action. 

It’s really combining, as you said, the consumer devices that are becoming so available and the prevalence of using voice as a user interface and speech recognition as a user interface, combined with the intelligence and routing capabilities of our software, and then the connectivity that we have out to the employees of the hospital. We’ve shipped over a million Vocera badges out into the marketplace. There are hundreds of thousands of people using them every day. That gives you an instant connection to nurses, transport techs, housekeepers, and food services. A patient can get immediate access to all those people, rather than it just being a hardwired connection back to the nurse station, where someone then has to figure out how to deal with that patient’s request. We are seeing a convergence of technologies that people have become used to and comfortable with in their personal lives and in their homes, merging with hospital-specific workflows and hospital-specific solutions that leverage the sophistication that we can build within software.

How has COVID affected the use of your products and the trajectory of the company?

The pandemic has raised the awareness for our company, our solutions, and the value proposition of what we offer, in particular, the hands-free capability. Every time a care team member removes or replaces their PPE, there’s a risk of contamination. Minimizing the number of times PPE is removed reduces the risk of infection and helps preserve these valuable resources. Whether that’s in a triage tent, an ICU room, or an isolation room, the hands-free capability of our solution has been really valuable, because it can be worn underneath the personal protective equipment.

We have seen the product being used in temporary tents being set up to triage patients. We’ve seen the Vocera badge being used connected to the bedrail, to allow patients to reach care team members and for nurses to do virtual rounding, where they can call a patient’s room instead of going in and out for a quick conversation, which keeps them safer and reduces the amount of PPE used. It allows them to reach out to family members. It has been exciting to see the role that that communication can play.

For our employees, our connection to our mission has never been stronger. Our mission is to improve the lives of caregivers, patients, and family members. While the pandemic has been tragic in many regards, it has been inspiring for the employees. Our level of employee engagement is higher than it has ever been because we have been part of the solution. It has been inspiring for employees to feel like they are doing something that is having a direct impact on patients, caregivers, and family members.

What sales and marketing changes have you made given travel limitations and the cancellation of HIMSS20?

We were one of the first companies to drop out of HIMSS when we saw the pandemic rising. Maybe it was the benefit of being out here on the West Coast and seeing what was happening in Washington. But we very quickly started transforming the company to being virtually oriented in our sales, services, and marketing efforts.

Just to give you an example, within 30 days of this all coming about, about 90% of our professional services had been transitioned to remote work using Zoom or other virtual technologies. Our sales team quickly embraced reaching out and working with customers on a virtual basis. Our marketing team did a really good job of creating new use cases and case studies talking about COVID-specific workflows and how the product could be utilized in these environments. We used it as an opportunity to support our customers. We issued several thousand free, temporary license keys for our software to customers who needed to increase their capacity to respond to COVID surge situations.

I’ve been incredibly proud of the response by the company and by the employees to support our customers and do the right thing during these really challenging times.

How do you position your offerings in rounding, patient experience, pre-arrival, and patient monitoring software within the framework of enterprise communications?

Our vision is around enabling the real-time health system across the care continuum. That is more than just voice communication. It is more than just communication broadly. It is all about eliminating the friction points in a patient’s journey and making sure that the right data is delivered to the right person, on the right device, at the right time, with the right level of urgency.

Take as an example our recent acquisition of Ease, which is a patient and family communication application. It enables caregivers to give updates to family members when a loved one is in the hospital for surgery, COVID, or other situations that prevent family members from visiting them. This speaks to our desire to expand to enable this real-time health system.

The company has its roots in the Star Trek communicator kind of mindset, but our software platform is much broader than that now. We have had to evolve as the industry’s has evolved. In the old days, a lot of actions in a hospital were triggered by a nurse walking into a patient’s room and noticing a change in their condition. The workflow started by the nurse needing to reach out to get the appropriate help. More and more today, patient monitors, physiologic monitors, smart beds, and the electronic health record are becoming expert systems. They can, in many cases, notice a change in the patient status quicker than the nurse who is walking into the room. The event that needs to be triggered from that, and the people who need to be activated as a result of that change in patient status, can be coming from lots of different sources beyond just the initial human interaction with the patient.

As a company, we focus on evolving what we do to be able to incorporate all this data coming from these expert systems, route it through our workflow engine, and more importantly, prioritize it and triage it so that we aren’t creating cognitive overload or cognitive burden on the clinician, so that they’re receiving just the most critical information. and know the most important activity to act on next.

You are at a blurred line between what you’ve traditionally done and new technologies that are gaining in popularity, such as chatbots, artificial intelligence-powered population health management, asynchronous text-based provider chatting, and patient-reported outcomes, all of which are usually offered by a standalone startup company. Do you see Vocera getting more involved in either these specific technologies or with those companies that offer them?

You’re absolutely right. Hospitals tell us all the time that they are looking to consolidate the number of vendors that they are working with. They are looking to build platforms that are unified and fully integrated.

We try to create as much of an open platform as we can. We want to be interoperable with data from a range of different systems. Whether it’s a piece of technology that we develop ourselves, creating an interoperability relationship or some sort of partnership, or a potential acquisition — those are all ways of building up a platform that is easy to use and is delivering the right information to the caregiver.

I love to see the innovation that is occurring in the space, because the more information and the more data that gets generated, the more of an opportunity there is for us to analyze that data, route that information, and provide better patient context. When a call or message comes in, it’s not just an interruption, it’s actually patient context-aware events that provide the caregiver with situational awareness that allows them to decide what the next action is.

Our strategy is to say that we are going to do a lot of this ourselves, but we’re also going to create open APIs and open standards that allow us to bring data in from other organizations. One of my favorite examples is sepsis alert technologies, those sophisticated algorithms that can  predict when a particular patient might be headed towards sepsis. The challenge with those is that often that the algorithm can identify the patient who is at risk, but it may not do a good job of notifying somebody who can take action. In that case, we do a simple integration with them, they send us that alert, and we route that to the appropriate caregiver. They can take action much more quickly than if we were just waiting for the clinician to go log into the electronic health record or some other expert system that has identified that the patient is at risk.

Do you have any final thoughts?

Technology vendors have an important role to play in transforming healthcare, whether it’s providing improved safety for clinicians and for patients, reducing the cognitive burden, our doing a better job of protecting our frontline caregivers. Technology must be part of the answer to bridge the gap between where we are and where we need to go. Vocera is really excited to have an opportunity to participate in that.

HIStalk Interviews Blake Marggraff, CEO, CareSignal

Blake Margraff is CEO of CareSignal of St. Louis, MO.

Tell me about yourself and the company.

I co-founded the company CareSignal, which was previously called Epharmix, and I serve as CEO. CareSignal is a simple enough concept. We create device-less remote patient monitoring solutions to help support risk-bearing providers, payers, and the patients or members they serve, with a primary focus on chronic condition long-term management and support.

What led you five years ago — as a 22-year-old coming out of pre-med — to form a company in an industry that is notoriously hard for newcomers to crack?

There’s a pragmatic answer and a philosophical answer. The pragmatic answer is that I saw an opportunity to do one of my favorite things, which is to orthogonally combine technology – which, to your point, a lot of people have thought would work by itself and hasn’t — with evidence. The basis of our company is evidence first, sales second.

Philosophically, though, if I could spend my time doing anything, I want to be able to look back in one month, one year, 10 years, 50 years, and be proud of the impact it had and the scale of that impact. I think healthcare, and specifically health technology, is the best one-two punch out there.

Some wellness technology companies offer solutions that, if they work at all, won’t deliver ROI for years, when the cost savings of improving chronic conditions will finally pay off for some other employer or insurer. How do you approach a prospect who questions return on investment?

These are two really important concepts. The credibility of the argument, fundamentally, always involves return on investment. That credibility comes in the form of defensible impact clinically and then financially, but also the time horizon of that impact. Getting a person to stop smoking is a good thing, but financially it might not actually be a good thing for one, five, or 10 years.

To the people who have abused the concept of evidence-based or clinically validated outcomes — and you can bleep this in the written version — but frankly, f*** them. They are treading on one of the most elegant and powerful parts of medicine, which is the concept that you can advance the standard of care by thoughtfully conducting high-impact research and iterating on innovation in the process.

In terms of CareSignal, we announced recently that we now take risk on any contract we sign. We are confident that we can engage through all the patients, drive clinical outcomes, and return financial benefit to our partners with the time horizon of less than a year, and generally within six months. That touches on all the points that you mentioned. It’s not enough just to do it — you have to do it in a way that is financially compelling to your partner.

What portion of patients show a willingness to interact honestly with automated messages about a concerning condition, but would not have taken the initiative to reach out directly to their provider?

You are hitting on selection bias, and maybe touching on the transtheoretical model of behavior change as well. It is true that some healthcare innovations can only help people who want to be helped. That’s always true to an extent, but I fundamentally reject that as a barrier to bending the cost curve, or even engaging the vast majority of patients who need to be engaged and supported.

The argument that I provide is a simple one. When providers, meaning physicians primarily, want to effect change, they leverage this power of the prescription. There is still an element of healthcare that is relationship driven, stemming from the strong relationships that many providers still have with their patient populations. The best technology sits at that intersection of clinical and relationship.

Does the political concept of campaigning only to the undecideds make sense in population health management in focusing resources on patients who are most likely to benefit from health messaging?

I don’t have deep background, so I’m almost wary of speaking to that and I would just be pontificating on it. I will say that looking at chronic conditions, there’s kind of an ironic behavior trend that we see across our patient population and partners. Patients who are doing just fine wind up disengaging faster than patients who are experiencing adverse outcomes or adverse symptomatology. The heart failure patient who hasn’t had pedal edema or nocturnal dyspnea for months, maybe even years, is going to be much less inclined to stay engaged and to provide clinically helpful, actionable patient-reported outcomes. Whereas the one who’s struggling is going to do so more.

A well-designed system will support people who are doing just fine for the long term, but will then allow the benefit to be had by the people who decompensate or get worse, whenever that happens, and that could happen a month or a year down the road.

Does the interaction between care managers and patients in your system populate other systems, such as EHRs?

Absolutely. CareSignal can operate as a standalone system. That’s important because a lot of groups need to operationalize and prove any new partnership or investment. We integrate with Redox and have a whole lot of respect for Niko, Luke, and the team. They can integrate with any EHRs that they touch.

Providers might react to a patient’s response to automated messages by either assuming that they are fine or that they need to come in for an office visit. What other kinds of communication do you see?

Our system is white-labeled, so from the perspective of our partners and patients, it is always their system. It’s essentially a warm line that is always ready. For patients who are in that rising risk bucket with barely-controlled chronic conditions that could go south at any moment, having a direct line to the care management team that you already know is powerful.

How is your system being used differently in the pandemic?

It’s just being used more. I’m grateful for the new opportunity from a business perspective, but the whole team and I have been pretty humbled to see that it’s doing what we always thought it could do in virtual health. Telehealth is table stakes and is increasingly quite present and quite high quality, but providers especially are emphasizing the need to defend relationships and grow revenue, and sometimes the reverse depending on their financial position. It’s the long-term engagement, ideally long-term, clinically actionable engagement, that seems to speak to them as we all go through this frustrating process.

What advice would you offer to people like you who didn’t come up through the health IT ranks or who may be disappointed by its bureaucracy and long purchasing cycles?

There’s a great mental model of Chesterton’s Fence. A couple of guys come across a fence in a field. One says, “Let’s tear this down. This is stupid. This is pointless.” The other guy says, “That’s fine. You can do that, but at least first tell me why it was built.”

That’s how I approach a lot of the conversations. It can seem like there’s too little of one type of thing and there is too much of another thing that seems unnecessary. You have to understand why it was put there in the first place if you’re going to effect sustainable change that will benefit all of the stakeholders. I guess that has  brought me to the conclusion that everybody in this space deserves a huge amount of respect, if only for their patience and often their iterative investment in a pretty weird industry over the past decades.

What is good and bad about how investors may take a company in a different direction that it originally planned?

Founders have to remember that investment is a means to an end. Folks who want to raise money so that they can raise money … most investors will not invest in that type of founder or business. More positively, I can cite investors such HealthX, UnityPoint, OSF, and others that are deep in healthcare, as well as many more that are immediately adjacent to health IT. They are run by operators and industry incumbents. It’s too complex of an industry for me to think that I can come in and figure everything out. The best investors not only provide good direction, but help you learn faster.

You started your entrepreneurial journey at a young age. What do you hope to accomplish?

Impact. Help as many people as possible live better lives and live longer lives. It comes back to the beginning. That’s what keeps me so motivated, even in a sometimes slow-moving industry, to keep pushing.

HIStalk Interviews Scott Weingarten, MD, Chief Clinical and Innovation Officer, Premier

Scott Weingarten, MD, MPH is chief clinical and innovation officer, Premier; professor of medicine and consultant to the CEO, Cedars-Sinai; and health sciences clinical professor at the David Geffen School of Medicine at UCLA.

Tell me about yourself and your work.

I’m an internist by background. I have been associated with Cedars-Sinai for many years. I have a passion for improving the quality of patient care. I have been focused on clinical decision support and information technology as a means to an end, with that end being better patient care. I started a company out of Cedars called Stanson Health. It was acquired by Premier about two years ago, and I’m now chief clinical and innovation officer at Premier.

How is Premier, along with its companies Contigo Health and Stanson Health, addressing clinical variation and waste?

Premier has rich data and analytics assets that can identify opportunities to improve outcomes of care, mortality, morbidity, and cost of care. The question then becomes, after you’ve found an opportunity, how do you realize that opportunity and demonstrate improvement?

One of the most effective, scalable, and sustainable strategies is providing context-specific information to healthcare providers that are integrated into the workflow, offering suggestions to the doctor or other healthcare provider to inform care that, in some cases, will change care for the better to be more consistent with the evidence. That’s a way to close the loop in not only identifying opportunities for improvement, but implementing those improvements and being able to measure their impact or being able to measure the actual improvement.

After the acquisition of Stanson by Premier, Contigo was formed. Contigo, as a company that is part of Premier, works with employers who have a vested interest in improving the quality and reducing the cost of care for their employees.

Is information sharing among peer health systems, as is done through Premier and vendor-sponsored programs such as Epic Health Research Network, having a significant impact on patient care?

Yes. Data is critically important to understanding the gaps between current care and optimal care. In addition to data, it’s what you do about the opportunity you recognize. How do you bring about those improvements and be able to demonstrate to your satisfaction and everyone’s satisfaction that care has improved, and significantly improved?

So sharing of data is critically important, but perhaps equally or more important is being able to change care. When I say change care, it’s the interactions among doctors, nurses, pharmacists, and the patient that lead to better care with lower mortality, morbidity, and cost.

Sharing of data is the beginning. It’s necessary, but far from sufficient. Sharing of data alone will not bring about improvement.

Is it a positive development that COVID has created an urgent demand for data in the form of anecdotal findings, observational studies, and pre-print research results that would have been delayed for years otherwise to meet formal research standards?

With a caveat. The Institute of Medicine – now the National Academy of Medicine – shared years ago that there was a 17-year delay between the discovery of important data that could save lives  and the time when that knowledge is translated into practice. That’s bad. Seventeen years is far too long, and efforts were made to shorten that gap significantly to save lives and improve care. I applaud that effort to disseminate valid scientific evidence as quickly as possible.

Pre-print publications, as we’ve seen with COVID-19, can be very helpful.  But it’s also important that the information be rigorously reviewed for scientific validity, because invalid information that is disseminated and translated into practice can be potentially dangerous. We want to shorten the gap for scientifically valid, scientifically credible information, that gap between when the discovery is made and when all patients benefit from that information. But we want to remain responsible that the information that’s disseminated proves to be scientifically valid.

Clinical decision support and evidenced-based medicine are sometimes seen by physicians as intrusive, where they trust their personal experience and practices more than the results of someone’s study. Are we seeing any new capabilities or use cases that would lead to their wider acceptance?

I believe so. The key is providing physicians, nurses, pharmacists, other healthcare providers with information that is integrated in the workflow that they find helpful, that will help them take better care of patients rather than being annoying. One of the best ways to do that is to suppress the information when it just validates what the physician or healthcare provider was going to do anyway. Only provide that information when it’s incremental to what the healthcare provider is already doing or informing them when whatever they are doing is in conflict with the evidence.

There may be many good reasons that it’s in conflict. Maybe they offered the patient a treatment where the evidence has shown that the treatment can be effective, but the patient, for whatever reason — sometimes a very good reason — refuses to take the treatment. But you always want to make sure that the care is informed by the latest scientific evidence.

Another development to improve the precision and value of the information is to examine the free text information in the electronic health record. Not only discrete data elements — such as demographic information, medications, or laboratory values — but the notes that the provider has written in the electronic health record. To be able to read, interpret, and contextualize the notes to further guide the clinical decision support that can be potentially be most effective for an individual patient. It’s really a type of precision medicine, where to the best of your ability, you get to know the patient based on what is recorded in the electronic health record and tailor the guidance for that specific patient when the evidence suggests there is a testing strategy or treatment that would be best for the patient.

Have EHRs gotten better at surfacing information that tells the key story of the patient and the clinicians who have treated them so that a quick glance at the electronic chart provides the most situationally relevant information?

Electronic health record vendors have worked very hard at solving this problem. They’ve certainly heard from healthcare providers that this is an important issue that needs to be solved, and that it contributes to burnout. But I have heard that in the United States, notes of healthcare providers are much longer than those of our colleagues in other countries in Europe and so on. If that’s true, then we may be inadvertently contributing to this issue.

The question is, how can we — in addition to the electronic health record vendor — help solve this problem? Can we have shorter notes, where the high-value information, the clinically important information, is still available to other healthcare providers, and potentially the patient if OpenNotes or other strategies are used to enable patients to retrieve the information in the notes? How do we, together with the electronic health records vendors, make the notes more concise, easy to read, and easy to interpret in a short period of time?

What is the status of large health systems, such as Cedars-Sinai, getting involved with health IT accelerators, health IT investment, and acquiring commercial businesses?

I think you’ll see some health systems, not all health systems, having a greater interest in accelerators, venture capital funds, and even creating companies or spin-outs for a variety of reasons. Out of Cedars-Sinai, my colleagues and I created two companies, the order set company Zynx and my current company Stanson. We were able to commercialize the IP, which was largely related to clinical decision support, and sell both of those companies. 

You will see this trend continue with some health systems, in particular, with academic medical centers. They are in the business of creating a new knowledge and discovery and disseminating that information to improve patient care, not only at their own organization, but across the country and potentially globally.

In addition to publishing the results in peer-reviewed journals, a way to increase the impact to a greater extent is to commercialize or productize that IP so that it can be used across the country and around the world. Many health systems will say that is consistent with their mission, including academic medical centers.

The second thing you will see is that patient care revenue is increasing very slowly. In many cases, wages are increasing faster than patient care revenue, so some health systems are looking to diversify their sources of revenue. You hear about health systems thinking about creating startups, creating accelerators, and having venture funds.

What technology and data needs have been exposed by COVID that will accelerate future development and adoption?

The American Recovery and Reinvestment Act was a very large subsidy of electronic health record purchases, installments, and implementations in physician offices and hospitals. However, with that investment, there was a very small investment in comparison in public health infrastructure. We’re finding that public health information technology infrastructure has lagged significantly behind, and we are reading almost daily of the consequences of not having state-of-the-art information technology for our public health professionals across the country during a pandemic.

COVID-19 will change healthcare and the way it is practiced for the foreseeable future in many ways. We’re going to see investments made to upgrade to 2020 standards the public health information technology infrastructure to benefit from the information in the electronic health records, so that we are ahead of the curve and ready for the next pandemic, for bio-terrorism surveillance, and for understanding the next carbon monoxide poisoning or diarrheal disease outbreak.

What personal characteristics and practices allow you to be involved in so many things simultaneously?

I have a certain intellectual curiosity that causes me to do a number of different things. Some might question how well I do any of those things. But the underlying theme is that I have a passion for improving care. My mission is to make a contribution to improving patient care. I’ve set out to fulfill that mission through a variety of things — direct patient care, academics and teaching, implementing quality improvement and value improvement strategies across a health system, and creating businesses that hopefully will enable health systems across the country and beyond to improve care. That’s the underlying theme of all of my attempts to make a difference.

Do you have any final thoughts?

As someone who has been in clinical decision support for over two decades, I’m now quite bullish on the field. I feel like the advances in technology, electronic health records, natural language processing, machine learning and AI, and speech recognition will enable transformation and significant improvements in the field of clinical decision support. I’m quite hopeful and optimistic that we’re going to see greater improvements in patient care from clinical decision support in the future than we have in the past.

HIStalk Interviews Bill Grana, CEO, HCTec

Bill Grana, JD, MBA is CEO of HCTec of Brentwood, TN.

Tell me about yourself and the company.

I am a technology entrepreneur, going on nearly 30 years. I have been involved in starting, investing in, and leading high-growth tech product and tech services companies, many of which have been related to healthcare or HIT. I’ve been with HCTec for three years.

We are an IT services business that is focused exclusively on the hospital system sector and other specialty providers. The tagline of a German multi-national chemical company used to be, “We don’t make the products you use. We make the products you use better.” In HCTec’s case, we don’t make the technology that is used by hospital systems. We make the technology work better through our team of talented IT professionals with specialized IT skills.

How has your business changed with the pandemic?

Like many other businesses, we transitioned to full remote work in early March. I’m very pleasantly surprised and proud of my team for how well that they executed that change. We haven’t missed a beat in terms of service delivery with our clients, more specifically with our two primary business lines of consulting and managed services.

We’ve seen the consulting business negatively impacted. As hospitals experienced stress, particularly financial stress, one of the first things to be cut was contingent labor. A number of our contract consultants were released. But we are seeing that pick back up. On the managed services side — where we provide both an IT help desk solution as well as application support for current generation and legacy systems, primarily focused on the enterprise EMR — that business has stayed robust. We have seen huge volume increases on the help desk side tied to the transition to remote work, but particularly telehealth. So it’s been a tale of two different worlds in terms of how COVID has impacted our business.

Is remote work for go-lives and support here to stay, or will onsite work bounce back once travel limitations ease?

Much of that is going to be here to stay. There is no reason to revert back to what it was pre-COVID, assuming that from a service delivery and outcome perspective, it can be equally effective. From a cost perspective, it’s certainly better for hospitals to do it that way. In many cases, it’s better for the consultants who are providing the work to be able to do it remotely, whether it be from an office setting or from their own homes, rather than having to get on a plane at the beginning and end of each week.

How are health systems prioritizing their IT projects differently?

The projects that were put on hold in March and April are beginning to be resurrected. The contingent labor that is necessary to execute those projects is coming back as well. I think that the demand will return to pre-COVID levels. We will see more openness to remote work by consultants. Many of our hospital clients have moved the entirety of their IT organizations to remote work. That will give them a greater comfort level that their vendors and partners can do the same thing.

The COVID experience has opened the eyes of health system IT departments and leaders to the importance of having partners that can be nimble and react quickly in unforeseen circumstances like this. We have demonstrated that in a number of ways.

I hate to use the word “outsourcing,” because it is considered a dirty word in many circles. But I think we will see health systems take a hard look in the mirror, not just with IT functions, but more broadly, in asking the question, what are truly our core competencies? For many hospitals, that is provider support and high-quality patient care. Everything else, in many cases, can be performed as effectively or more effectively at a lower cost by a partner or some sort of alternative labor arrangement beyond just hiring full-time staff.

We’ve seen Optum announce a couple of deals over the last 12 months where they are taking over all non-clinical operations. I think that trend will continue. Maybe not necessarily a full partnering, but more of a best-of-breed approach, where companies like HCTec will step in and provide services that are important, but that aren’t necessarily core competencies of hospital systems.

We’ve seen those deals ebb and flow, however, where hospitals outsource core functions but then bring them back in-house within a few years. What are the success factors in making outsourcing more than just a short-term experiment?

There has to be a clear cost justification, where the partner can provide the same service at the same or lower cost. The same principle applies to quality, where there must be service level agreements and metrics that the vendors are held to, with penalties or other consequences to the extent that they fall short.

These things go in cycles, but I believe that the COVID experience will encourage hospitals to look at partnering with firms in non-core functions in a much bigger way than we have seen.

How do you explain strong investor interest in the health IT sector even as its health system prospects are struggling, at least temporarily?

Some categories have been really hot. A lot of money has been invested in telehealth following the boost it received as the result of COVID. Artificial intelligence and analytics solutions represent huge opportunities in the long term. Outside of the IT segment, a lot of investment has gone into services side and into different specialty ambulatory practices as well.

I don’t know that any of those things will last into the future and provide an opportunity for growth. Sectors get overheated. It’s hard to fathom the valuations that go along with some recently announced deals. I guess my small brain is not smart enough to get wrapped around that.

But overall, I think the health IT segment is a very attractive long-term investment sector. As we think about what healthcare looks like in the future, it involves a greater adoption, prevalence, and reliance on technology to support clinical service delivery and hospital operations. We will certainly not see less of that in the future. You could probably say this to a degree about any market sector, but I healthcare is particularly ripe for technology that can benefit its performance.

Telehealth boomed early in COVID, but now it seems to be cooling off everywhere except on Wall Street. How will it play out in the next two to three years?

We’ve already seen the levels pull back from what they were as people become more comfortable returning to their physician’s office. But there are certain use cases for telehealth. Behavioral health is one example, where it can arguably be delivered even more effectively via telehealth, in a way that makes the patient more comfortable or more apt to seek help where there may be some behavioral health challenges.

But clearly, if you need a physical — at least given where we are with technology right now – you have to go to the doctor. Over the next five to 10 years, I think that could change with different and improved patient-facing technologies and monitoring devices, where much of your regular physical could be done from home or outside of a doctor’s office.

What technologies hold promise now that EHRs and stable infrastructure are universal?

It’s probably overused, but the digital front door, creating a single entry point for customers, or patients in this case, to provide an improved overall digital experience. It is disjointed with many health systems and across providers today. It’s hard to navigate, even for folks who are technology savvy and Millennials. Effort and emphasis will be placed on that.

You see the same thing in the financial services marketplace, even though it’s probably several years ahead of healthcare. I’m on the board of a financial technology business and I chuckled at our last board meeting, where they were talking about all these banking institutions that are focusing on the customer digital front door. The exact same thing is happening in hospitals.

We are in the nascent stages of bringing a mature experience to market. It’s about the customer, or again, in this case, patient experience. As systems compete for patients, it will be important to give them a strong digital experience.

Will small health systems lose to the bigger ones that just keep getting bigger, as happened in banks that bet big on expanding outside their regions and deploying technology such as ATMs and online banking that customers valued?

It is probably not necessarily the best thing for the marketplace, but I do think that that’s the case. COVID has accelerated that with the financial stress that has been placed on smaller institutions that don’t have the balance sheet to weather the storm. We’re already seeing consolidation happen that would not have without COVID. The same holds true for the ability to invest in these digital and patient-facing tools that drive the whole experience.

What will the company’s direction be in the near future?

The future is bright, despite the fact that we still have COVID hanging over us. It will dissipate, hopefully sooner than later. From a service portfolio and capability perspective, we are well equipped to meet current and future demand, and with some incremental changes, to realize some additional opportunities.

We’ve put a great team in place. I wouldn’t have wished COVID on us, but it has given us a little bit of breathing room to focus on operational improvement that is already making a difference in our current business of quality of service delivery to our clients, and will continue to make a difference in the future. Growth and improvement remain continuous and will be future themed.

Do you have any final thoughts?

The pandemic has put healthcare clinical workers in the spotlight in a well-deserved way that was not seen previously. We also need to recognize the people who are behind the technology that is used by hospitals, the improvement in healthcare delivery and the extra hours and work that they put in during this challenging time.

Technology doesn’t always work as it was designed, and in those cases, we need experienced people with specialized skills to provide support and continuous care and feeding to maintain the health of these hospital tech ecosystems. That is the essence of who we are and what we do at HCTec.

HIStalk Interviews J. Erin Hutchinson, Owner, Narrative Shift

J. Erin Hutchinson, MA is owner of Narrative Shift of Herbster, WI.

Tell me about yourself and the company.

I’m a Midwestern farm girl, so I don’t like to talk about myself, as most of us don’t. I’ve spent my career starting companies, starting with clothing stores and video store chains. I have 45 years’ of experience in the healthcare technology world. Ten years ago, after launching many small ventures, I started what is now Narrative Shift.

We help founder-led companies and startups in the healthcare and biotech space successfully launch their products and services. We help them craft compelling narrative to create curiosity and excitement among their target customers so that they are interested in having a conversation. All of us are bombarded with lots of shiny marketing stuff, but it’s hard to get your message out there so that people take action and have that initial sales conversation. We do full-service graphic design, marketing, and go-to-market strategy. It’s a startup advisor in a box, as I like to say.

You went from being a psychologist to leading teams at Epic, engineering companies, and consulting firms. How have you applied your psychology knowledge in those roles?

I worked for Epic back when it was fewer than 100 people. In my late 20s, I was working with physicians and surgeons who were new to technology, to the point that I had to teach them how to turn on a computer and use a mouse. A surgeon threw a keyboard at my head once, so that’s when I used my clinical psychology skill set to get people to change.

In helping new companies get launched and bringing more revenue to tech startups, I draw from that background of how we communicate and connect with other people. Companies tend to get myopic. They may have the best thing since sliced bread, but they lose track of being able to put themselves in their customer’s place. I help these companies craft their identity and craft their story so that it is communicated and connects with their target audience.

Tech people are not always the best at the human element, so my background has helped a lot. Plus I was a child and adolescent psychologist where humor is important, especially when you are working with young kids. I bring that to my work with my clients. Starting and growing a company is hard work and I like to bring a little bit of fun to that.

What is narrative therapy?

I was trained in, and my dissertation was in, using the narrative approach in working with children and adolescents. I could bore anyone to tears with all of the heavy post-modern theory aspect of narrative therapy, but in essence, it’s that we as humans create meaning and communicate with each other through through narrative, through stories. That is the core element of how we express our experience. The essence of successful design and marketing is that you have to communicate to your customer through a story.

Bringing the narrative therapy approach involves working with your clients to understand the narratives that shape their world view, and then working with them to re-author those in the way that they see themselves. Maybe they can re-author their narratives to psychologically shift their perspective.

Founders are usually interesting and have a lot of personality and humor, but they seem to be coached into dullness as their companies grow, to the point that all communication is filtered through conference rooms pull of people who suck the life out of it. Can large companies be interesting and fun?

To be 100% transparent — and sometimes I’m painfully so — one benefit of owning a company is that you can choose to be that way. I choose not to work with many large, established companies. They are either overly prescriptive about “this is how we must present ourselves” or they have armies of corporate marketing people who are maybe good at putting on events, but not so great in figuring out better ways of connecting with their customers.

We in healthcare are do a really bad job of using creative ways to get the interest of target customers and target markets. I set a rule with clients that if they want shiny, happy stock photos of people who look like doctors and nurses, then they need to find a different agency to work with. I generally shy away from those companies that grow and become the Borg.

Early-stage or founder-led companies, which more often maintain that entrepreneurial culture, are more open to being creative and asking for help to find their voice, establish their identity, and craft the narratives that will get prospects interested. I’m probably trying too hard to be politically correct in saying that big companies are boring. Those that grow successfully need to maintain that fine line, but cut through the noise by being a little bit irreverent and not being afraid to try something different in their marketing. It’s easier to do that if you have strong leaders who maintain that entrepreneurial spirit and don’t hire a bunch of marketing Borgs or large agencies without experience in healthcare or healthcare tech, which perpetuates this culture of stock photo websites and material and messaging that all looks the same.

How much do you help create strategy rather than just communicate it?

It’s a little bit of both. I love working with smaller companies and startups because I’ve been in the role of starting companies. I’ve been a part of many ground-floor new ventures. I’ve done the work. I didn’t just get a marketing or design degree. I’ve gone through the process of getting funding and I know what that takes.

With my background as a therapist, many clients ask for help because they hate their website or their sales pipeline isn’t growing. But most of the time, that ends up turning into a combination of helping to craft the strategy, especially from a go-to-market perspective, as well as the messaging and those narratives. I find it impossible to separate those two. Maybe it’s because I’m opinionated, honest, and open that I can’t hold back, so I give my advice and clients can take it or leave it. I can’t just churn out stuff that looks pretty and sounds good. If I can help someone with their strategy and to be more successful in growing their company, I’m going to do that.

Because of my background and being one of the few firms out there that specializes in the provider market, they don’t have to spoon feed me and educate me on their business and their customers. I know it. That also helps me to be more strategic and holistic in the work that I do with my clients. It also means they don’t have to go through the agonizing process of writing a lot of copy for me to clean up because I can already articulate what is needed to their customers.

Social media tech companies have embraced psychology in ways that aren’t entirely positive, getting people to keep coming back, pushing analytics-targeted ads, and entertaining them with short videos. Does that change the way that companies might get and keep the attention of prospects?

Because of the evolution of media and how people consume information, there’s no longer a standard recipe of what will work for a particular type of company or customer. I tell clients that some things aren’t worth wasting your time on. You aren’t going to get a hospital CEO to call you just because you have a great Twitter feed. Some clients I’ve worked with think a social media presence will magically result in more customers.

I wish that the diversification of media and expansion of the ways people get information make it easier to grow your company and to get the attention of your customers, but frankly, it has made it a lot harder. You have to spend more time understanding who they are, developing your buyer personas, and then figuring out where they are. What are they looking at? How do you get in front of them and get their attention? You need to have a multi-pronged approach. We no longer have four TV channels, three radio stations, and two newspapers.

It goes back to psychology understanding. What do you have to offer? What is your secret sauce? What makes you special? Whose attention are you trying to get? The psychology component gets infused into figuring out which tools to leverage and crafting campaigns and materials that are targeted at these types of potential customers. That was simpler before social media.

Some companies based their entire marketing strategy around the HIMSS conference, then reaped whatever benefit they received for a whole year. How will that change in the absence of in-person conferences for now and with provider customers whose priorities are dramatically different than they were six months ago?

I’ll be blunt. If there is one upside to the pandemic that we’re living in, it’s that it upended the HIMSS apple cart. My guidance to clients for at least the last five years is, don’t do it – don’t spend the majority of your marketing budget on this one event. Feedback from the last 10-15 companies that I’ve worked with, which has gotten louder over the last few years, is that they sunk a ton of money into HIMSS and got next to zero return, other than meeting a few new people. I’m hoping that this has forced companies to reevaluate and rethink their spending. I will be curious to see, by the end of this year or the middle of next year, if companies look back and realize that HIMSS didn’t really impact their bottom line that much, and they got good results using other methods.

Will that level the playing field so that small companies can use creativity rather than a big bank account and sprawling booth to chase business?

The benefit is that people have to think differently about getting their name out there and marketing themselves. The benefit of in-person conferences was getting face time in forcing your way in front of those most likely buyers. The companies that will succeed now will be creative and able to adapt. That’s harder for a large company that has entrenched corporate marketing departments and strategies, where it’s harder to adapt and be willing to diversify in trying different things and methods. Established, bigger companies put 75% of their marketing budget into HIMSS or other conferences. Now there’s the freedom to take that money and be more creative and use a variety of marketing campaigns.

Smaller players are relegated to the HIMSS “basement,” sometimes literally on the fringes of the big show floor. This is a time where it’s harder to get healthcare buyers to pay attention to you. They playing field is leveled if you are creative an willing to try different things. Your prospects aren’t getting the impression that since you don’t have a big booth, you’re not worth talking to.

I live in a very rural, isolated part of the country that relies on tourism. I’m involved in the local farming and arts communities. We have offered for 15 years a local artist studio tour, with hundreds of people visiting this tiny town of 100 people that I live in. We couldn’t do it this year because of the pandemic, so we pivoted to a virtual tour. We’ve had three times the traffic as we had last year, which had been our most-attended year. This has made made everybody think differently about how you can market and sell art and for artists to connect with potential buyers as well as just people who appreciate art. Corporate America and companies that sell into the provider market might be surprised by the amazing results they can see if they connect with people virtually.

What psychological observations do you have from working in 100-employee Epic now that it’s 10,000-employee Epic?

They have had to adapt some things as they have grown, but I’m not surprised that the company’s culture has remained consistent, since it is 100% driven by the founder. She has remained consistent in her perspective on how she wants the company to be portrayed, even in things like not wanting to get a bunch of “professional” marketers and designers.

Back in the day, I was one of the people producing the UGM multimedia presentations. It was all employees, and now they have people they pay to do that. But the company has always been proud of not devoting tons of time and resources to sales and slick marketing, and that has helped them continue that same kind of vibe. Going back to pure psychology, Judy established the narrative of what she wanted Epic to be early on and has not deviated much from that as the company has grown.

Some great case studies will be written in the next decade or so that Epic didn’t follow the rules of the road, but still scaled the company without growing up, maturing, and making everybody wear suits. People will look back and see that you can be true to yourself if you establish that really strong identity and strong narrative. You can grow and become the monolithic, 10,000-pound gorilla.

Do you have any final thoughts?

Everyone is struggling. 2020 has been a year that none of us could have expected. If you are struggling, like we all are, this is a great time to reevaluate and take a look at how you are communicating and defining the story you want to tell. Think about trying something different, because honestly, what’s it going to hurt? The rules have been broken by the fact that we are living in a completely new reality. Have fun with that a little bit.