HIStalk Interviews Erik Littlejohn, CEO, CloudWave

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

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

Why do attempts to restore from backups fail so often?

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

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

HIStalk Interviews Scott Finfer, CEO, Emerge

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

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What does it take to sign new partners?

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

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

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

What is the direction of the company going forward?

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

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

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

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

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

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

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

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

Tell me about yourself and your work.

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

How is the Ease app that you developed being used?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Are you still involved with the product under Vocera?

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

Do you have any final thoughts?

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

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

HIStalk Interviews Marilee Benson, President, Zen Healthcare IT

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

Tell me about yourself and the company.

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

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

What kinds of interoperability projects are customers working on?

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

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

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

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

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

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

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

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

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

What unusual examples of interoperability have you seen?

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

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

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

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

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

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

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

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

How has the pandemic changed interoperability demand?

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

HIStalk Interviews Brian Schmitz, CEO, Clinect Healthcare

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

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

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.