HIStalk Interviews Tom Skelton, CEO, Surescripts

Tom Skelton is CEO of Surescripts of Arlington, VA.

Tell me about yourself and the company.

I’ve been in healthcare IT for a long time now. Believe it or not, it has been 40 years. The focus of my career has been digitizing healthcare, predominantly from the perspective of providers. Over time, it moved into different segments.

Surescripts has been around for 20 years now. It was stood up to solve some of the nation’s most significant problems. That was e-prescribing at the time, but we’ve expanded and broadened since then. We have never wavered from our purpose, which is to serve the nation with the single most trusted and capable health information network. Our focus remains patient safety, lower costs, and higher quality care.

How did use of the Surescripts network change with the pandemic?

Our focus has always been on either the prescribing process or informing care decisions and providing information to the caregivers, usually at the point of care. We saw a number of things occurring during COVID. There was a huge change in the telehealth landscape. Lots of new entities were springing up, and even within established entities, large health systems were innovating in the world of telehealth. We saw a much greater use of the network.

The other thing that happened was there was a greater focus on public health type information and the need to inform federal, state, and local agencies what was going on in the world of COVID. Folks repurposed some of our solutions to do that. For example, our clinical direct messaging offering was never intended to do that type of reporting, but that’s what people did with it. 

We think that that’s an example of how innovation is going to occur in the world of interoperability. We are all accustomed to certain use cases. We think that the consumers of those use cases are going to make those things valuable in ways that maybe we didn’t anticipate or intend.

What has the company learned in not just allowing healthcare participants to exchange information, but making the external information actionable?

It used to be that establishing a connection was a huge issue. It still takes a lot to do that and get it right, but that’s getting easier and easier. As it does, there’s a greater focus on the quality of the information that is being moved and how it appears in a natural workflow for the consumer of that information. Surescripts and our network alliance are focused on enhancing the quality of that information.

It’s making sure that the standards that exist — and there are many of them – are being implemented in a way that everybody agrees on how to utilize them and how to populate the individual fields or to populate the data elements. So that when it hits the workflow of a physician, pharmacist, or any clinician, it is appearing in a way that they can consume it and use it to enhance the care that that patient is being given. We see a lot of time and energy being put in to that.

Direct messaging seemed like it was going nowhere for a long time. How have you seen the Direct concept as well as your specific Direct platform progressing?

It’s interesting that you make that observation. That solution has been around for a while. It’s one of the few general solutions that exist in the world of interoperability. You are right that when it first came out, because it wasn’t use case space specific, people weren’t sure what to do with it. Over time, they are finding solutions here and finding that it can be an effective way to share information, provided that the sender and the recipient are on the same page in terms of what’s being said. We certainly saw that during COVID.

We are seeing a lot of work with that as we are working with health plans and helping them to do outreach to the physician community. These are the types of solutions that we are bringing to bear to help inform those care decisions that the prescribers, providers, and clinicians are making.

How do you see the information exchange market between providers and life sciences companies evolving?

Those companies have a a significant role to play here. They are major players in what goes on with the patient. They are obviously very interested from their own standpoint about what’s happening with the brands that they are putting out there. They want to know how their products are being used and what the adherence rates are. They want to make sure they are communicating with the prescribers. In many cases, they want to have access to the patient.

They have a great interest in the whole world of interoperability. We see that and understand that need. That’s one of the challenges we will face as interoperability grows. Life sciences wants access. Health plans want access. PBMs want access. One of the challenges for clinicians will be to make sure they are getting the right information without being overwhelmed with information.

How do healthcare networks add value?

An individual network can add value in many places. A lot of networks in healthcare are doing great work, whether it’s in the clinical world like we are, or whether it’s in the administrative world like some of the other folks.

Moving that information and helping to connect the ecosystem is a pretty daunting task. We have two million healthcare professionals. We are sharing actionable intelligence for 320-plus million patients. We are processing over 17.5 billion transactions a year. The role of the network continues to be not only facilitate that connectivity, but to ensure the reliance, the resiliency, the quality, basically the trust between the sender and the recipient and making sure that people that are requesting information are who they say they are and are entitled to that information and really do represent the patient that they’re requesting the information about.

There’s a lot that goes on there to maintain trust across the ecosystem. All of that contributes to how networks add value.

What influence will the Trusted Exchange Framework and Common Agreement have?

There’s a variety of mechanisms that the regulatory bodies are putting out there to help facilitate interoperability, whether it’s increased focus on standards, something like TEFCA, or whether it’s the information blocking legislation that was put through and is out there. All of that has value and helps to move it forward. It’s incumbent upon all of us in healthcare that are moving this information to tell our stories effectively as well.

One of the great challenges in the market is that each of us has an anecdote that we can tell that indicates that interoperability is not perfect. But we’re all moving a lot more information than we ever have, and it’s on us to share that information so that everybody understands how far along in the journey of interoperability we are and how far we’ve come. There’s still a long way to go, but a lot of good progress has been made.

The creation of those networks also creates business value. We’ve seen high levels of health IT investment activity and company valuations, but Surescripts has been quiet in terms of acquisitions or market transactions. Why is that?

We were founded to stand up one of the earliest networks in the market, particularly as it relates to clinical. Our goal here is a bit different than the goals of some of these other folks. We’re not chasing EBITDA. We’re not chasing an exit. That’s not what it’s about.

What it’s about for us is establishing, operating, and innovating on an existing platform that is neutral in the ecosystem, that is designed to facilitate the movement of that clinical information. Our growth has been driven by organic investment and continues to be driven by organic investment. We think that that’s a fabulous way to go. We think it also gives us the ability to take the long view and to make investments that other organizations may not be willing to make, and we think there are advantages there.

Where do you see the company in the next three to five years?

We are looking at what’s going on in the market and seeing many of the same things as everybody else. We’re seeing an increase in chronic conditions. We’re seeing the impact of high-cost specialty drugs. We’re seeing doctors facing ever-increasing rates of burnout. There’s a lot going on around us.

Our focus will be, number one, to sure that we optimize the prescribing process. We’ve got a lot of work to do in the area of specialty. We need to stay focused on that. We need to remove friction. We need to do things that advance and improve adherence and make it easier for all Americans to get the medications that they need.

The second thing for us comes back to that getting information to the provider community at the point that they need it. Solving that need for informing care decisions by giving them the actionable intelligence that they need and continuing broad-based connectivity for clinicians all across the market.

We remain purpose-driven. That’s who we are and we are very comfortable in that world. Our goal is to continue transforming these interactions among clinicians, pharmacists, and patients.

Do you have any final thoughts?

We’ve seen a lot of investments in the market. We’ve seen a huge influx of capital. We think that shows the amount of opportunity that there is here.

We think there’s a tremendous amount of room for innovation. We are excited about that. We see a continued acceleration of the trends that enabled virtual care. We think there’s going to be a lot of innovation to come that will help further information sharing across the healthcare ecosystem. The pandemic accelerated that and we look forward to continuing that over the next three to five years.

HIStalk Interviews B.J. Schaknowski, CEO, Symplr

B.J. Schaknowski, MBA is president and CEO of Symplr of Houston, TX.

Tell me about yourself and the company.

I’m a 25-year software veteran. I was with big publicly traded companies like Intuit, Sage Software, LexisNexis, CA Technologies, and Vertafore prior. I had done primarily go-to-market roles. I’ve done operations, M&A, strategy services, almost any job you can have inside of a software company. I spent about 10 years in the last two companies prior to this in vertical software. Legal for about four and a half years with LexisNexis, trying to help large and small law firms run better, and then the last almost four years at Vertafore, trying to help independent insurance agencies modernize their technology.

Symplr felt like an obvious opportunity, because at least from my diligence, there’s no more inefficient operational entity than some of these big healthcare systems. I thought it would be a great opportunity to bring my technology background and help modernize what is effectively the healthcare operational landscape at Symplr. 

That’s really what we do. We cobble together, consolidate, and standardize everything between ERP and EMR, where today there are hundreds of point product solutions, small companies all over the board on data migration, data security and privacy, and look and feel. We believe we can consolidate that into a single operational platform that allows CIOs, CMOs, and COOs to better run their healthcare systems to the benefit of not only the top and bottom line, but also operational efficiency as well as patient safety.

Can a company that has grown by acquisition keep all of its three constituencies of customers, employees, and investors happy?

It’s the imperative. The investment thesis for Symplr from our sponsors is exactly that. At the end of the day, world-class run companies with successful, happy customers are the ones that get world-class valuations. Our backers literally have a vested interest in making sure that we are solving for our healthcare systems. 

There are only 1,900 acute care systems in the United States. We have 85% of them as Symplr customers. If we’re not providing extraordinary value, if we don’t have good customer Net Promoter Scores, if they’re not really happy with Symplr all day long, this thing isn’t going to work regardless. Believe it or not, I 100% stand behind the fact that we as Symplr and our sponsors have to make this work for customers. If not, our sponsors won’t get the financial results that they want.

The company is looking for a financial transaction at a multi-billion dollar valuation. How would you characterize the health IT investor market?

You have three or four driving forces relative to the healthcare IT market today. The first one is that the pandemic shone an absolute spotlight on the fact that healthcare operations are wholly deficient. You’ve got physicians who can provide COVID care that can’t get tagged in from the sidelines because they can’t get credentialed for three or four months. You’ve got nurses on the evening news who are working 12- to 15-hour shifts without lunches because their staffing and scheduling systems don’t talk to their HRIS system, and that’s criminal. So now you have this imperative because of the spotlight on healthcare operations, and as a result, you’re seeing those companies inherently become more valuable.

The second thing is the cost of capital is still relatively cheap, and healthcare has always been a great place for investment. You are now seeing this modernization initiative take hold and consolidation within many of the largest systems, which will be good for technology providers.

Third, you’ve got some market conditions relative to what likely will be perceived as enhanced regulation, which typically is addressed with software businesses, particularly the governance and compliance area.

Those three areas are driving what is an incredibly hot healthcare IT market right now. Frankly, we don’t see that slowing down. It’s interesting because it’s making multiples meaty, to say the least. But Symplr’s strategy is to look for the right companies that add additional value to the portfolio that we’ve already built and strengthen our position in healthcare operations. We’re taking the more long-term views, and sometimes we might be willing to look into investment differently because we can look at it over time, not just in the next 12 to 18 months in terms of our returns.

Do those meaty market multiples give you an urgency to act quickly to find a buyer or investor?

The short answer from my seat is no. I have the benefit as the CEO of Symplr of making it the best healthcare IT software vendor provider in the world. If our sponsors look at high multiples and say, now’s the time to look for a new partner to change hands, I leave that in their hands, frankly. But I will tell you that I think it’s more indicative of the value that software modernization, technology modernization, can provide to healthcare systems. 

I don’t see healthcare technology multiples fading, because there’s so much value to be brought here. We are just cracking the surface on the potential of improving operational effectiveness of healthcare systems. I think that will only continue to rise as these systems truly embrace what technology modernization can mean for them. They start to stitch it together. They don’t have the data security and privacy risks any more. They have the data and insights to make intelligent decisions. They understand where they fit relative to other systems and peer community. I only see them going up.

People keep expecting technology to reduce costs, reduce inefficiency, and improve outcomes in healthcare, but somehow that never seems to happen at a macro level. Are prospective customers becoming more demanding?

Yes. People were still looking at this whole middle infrastructure realm in a point product way. The reality is you can keep investing in point products all day long, but if you don’t have better interoperability, if you don’t have a common look and feel, if you don’t have a common data layer that gives you better insights in how to run your healthcare system, you’re not going to see the benefits.

We’re seeing these top-down initiatives that are starting with some of the biggest healthcare systems in the world moving down into what I’ll call the more mid-market or mid-tier size healthcare systems. I’ve talked to some CEOs and CMOs who would reinforce this. As recently as seven or eight months ago when I joined, the theme was, we just let our facilities and our teams pick whatever solutions they want and we just make sure that we get the right price on them. Maybe there’s some data security and privacy standards, maybe there aren’t, which is frightening on so many dimensions. 

But now what you see is these large systems that keep getting bigger, they know they can’t run with 100, 200, 300 different point product solutions, many of which are trying to achieve the same outcome. They are now driving this consolidation standardization, not just as a technology, but of workflow and processes, such that you can  have a facility in Oregon and a facility in California and you can transfer an employee. A lot of those systems and tools are made the same way, so you can onboard them immediately and they’ll understand the look and the feel and the healthcare system’s way of doing things.

That’s going to be better for business. Number one, you get the obvious financial impact of system consolidation. But beyond that, it’s going to be so much better for the frontline workers who live in those in those tools for a couple hours a day who need to be as efficient and productive as humanly possible. When you’ve got a nursing leader who spends three to four hours a day of his or her time in systems instead of providing care or mentoring younger nurses, that’s horrible for your system. The ability to reduce that to an hour or hour and a half a day provides meaningful time back. That’s why you’re seeing a lot of these top-down down initiatives that previously had just been left to a fragmented, decentralized decision-making process. That’s the way of the past.

Has Symplr’s acquisition and operation of Phynd given you an appreciation for the challenges involved with the seemingly simple task of provider data management?

It’s so strange coming in from the outside. It’s a plumbing problem. If your pipes are set up the right way, your data flows. This shouldn’t be that hard. But because of the way credentialing takes place, because of the way a lot of these systems do provider data management, it’s been wholly inefficient. We look at Phynd as another part of provider management, which is one of the core categories that Symplr operates in as part of healthcare operations and GRC. If that front door doesn’t work, it  impacts the entire downstream operational landscape.

Phynd was so obvious for us. What had been Cactus and all the other provider applications we have that – Symplr Provider – and we saw the opportunity to bolt Phynd — now called Symplr Directory — into that and extend the operational wherewithal and competency in through the digital front door. Systems are now able to identify and convert more of those patient opportunities. It just made a ton of sense to stitch the whole thing together. It’s one plus one equals seven with those products together. It was a great opportunity for us to add a lot of value by simplifying something that shouldn’t be that hard.

You’ve said that companies need leaders who can stop debating and instead take action based on the 80% of information that is known. You’ve also said they must get along with each other. Did that mindset come from your military experience?

It’s this whole concept of task and purpose, and it really comes down to alignment and goal setting. If you have an organization that is trying to do too many things and doesn’t understand collectively what winning looks like or what success looks like, that’s when you get these rogue individuals who are well-intentioned, but are off doing their own thing. 

At Symplr, we have three strategic priorities — grow organically, become one Symplr internally and externally, and then win with mergers and acquisitions. The individual goals of everyone in the company, including me, ladder up to those three objectives. If you have continuity and consistency of purpose, the organization is able to better win together and remain aligned. We also have to know what right looks like, such that if someone is off doing something, the rest of the organization has a mandate to say, wait a minute, I think we’re out of balance here. How does this align back to our common objectives? 

Whether it’s in the military — where you basically have tasks and purpose, you have very specific missions with a specific purpose and clarity around mission intent – or in business — where you have three strategic goals, here are measures for each, here’s how your job ladders into each of those, here’s how we collectively in a system achieve those — it’s much easier to create organizational alignment.

I say I joined Symplr for four reasons, and one of the primary ones was the culture of Symplr when I walked in the door. This was a company that had grown up through acquisition. I was shocked to learn that the employee engagement was as high as it was. We had world-class Employee Net Promoter Scores the day I walked in the door, which told me you’ve got a workforce that wants to actually understand and solve for customers. That it’s looking for singularity of purpose, if you will. We’ve done a pretty heavy internal transformation to become one Symplr — our own infrastructure, our own processes, a common way of doing things. We do EMPS every quarter and we’re still world class. The organization was hungry for that kind of goal-oriented management and I think we have thrived as a result.

You are early in your first CEO job, but have already been involved in acquisitions and presumably some discussions about the possible change in company ownership form. What are you learning as the person who has to make those big decisions?

The two observations that I probably reflect upon the most are, number one, you can’t undervalue the importance of having an incredibly strong executive team. Do the leaders of the functions of our organization all understand what the goals are? Do we ladder up against them? Do we have the right culture on the executive team such that the organization sees us working together, challenging each other, but always being professional and having a ton of fun doing it?

I probably believed this before I took the Symplr job, but now I very much understand it because I own it as part of my job, but having the right executive leadership team, senior leadership team creates wonderful opportunities for engagement, for alignment, and for internal employee mobility. That’s what it looks like done right.

The other piece is that you never know, until you sit in the chair, how amazingly complex and varied the different parts of the business are. In the same day, I’ll go from evaluating our return to travel and the office COVID policies — relative to vaccinations and who is, and who isn’t, what do we do — to incredibly important diversity and equity and inclusion initiatives that we’re overseeing, to product strategy, to facility rationalization, to sales bookings growth. You get everything in the same day. If you’re not intellectually curious enough to be able to pivot five or six times in a given day and focus on different things, this could be exhausting. If you enjoy that, and thankfully I do, it’s exhilarating. But until you sit in the seat, you have no idea the amount of variety that goes into the day-to-day.

Some technologies found their way to success being led by top executives whose temper, insults, executive turnover, and micro-managing control were legendary. Does that approach still work, where one person’s force of will pushes the company forward even while alienating many of the people who work in it or with it?

A majority of those examples involve founders and majority shareholders, so they could get away with it. I would argue that nobody wants to work for a jerk. There are too many options, particularly in technology. If you are good, you can go work in a million different places and be treated really, really, really well. Our philosophy as an executive team is that we are ruthless in our decision-making, but we’re nice to everyone all the time. Because why would you not be? No one wants to do this if it’s not fun and enjoyable and if you don’t trust the people that you work with and for.

That other way may have worked. It may still work for some folks. It’s never been my style. You learn early on in your career that you can rattle your saber, shake your fist, and pound the desk and nobody cares. You’ll end up seeing higher degree of turnover and maybe the enterprise will be successful, but at what cost? As opposed to a place that is welcoming, nurturing, and accepting of all. That has high standards for performance, but just as an expectation of the role, never an indictment of the individual. 

We don’t yell. We don’t scream. Sometimes people work really hard, but hopefully it’s never all the time. This is not sustainable. I believe that the better financial outcomes come from happy and engaged employees, because then they’ll take incredibly good care of our customers, write great code, sell really hard, and market really well, and that will lead to the financial outcomes that you want. I hope those days are gone and you see more of a accountable, but accepting kind of leadership in technology.

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

I get this question a lot because of our size, growth trajectory, and profits. The financial profile at Symplr is just wonderful, so we have a lot of options. We might go public in a few years. We might remain privately held via a private equity sponsor. We may find a home with a very large strategic partner that thinks we can be accretive to their healthcare IT strategy.

More than anything, we’re focused on creating incredible healthcare outcomes for our customers, driving great growth as a result of that, and maintaining our financial discipline relative to the profit that we put off. If we do those three things, the options for Symplr will be unlimited. But the reality is that we’ll continue and maintain and extend our market leadership position within healthcare operations.

My dream is the day where healthcare systems, CMOs, COOs, CIOs, wake up and say, you know, we’re a Symplr shop. We use Symplr for provider management, workforce management, contract and spend access, compliance, quality, and safety. We’re a Symplr shop, which means we’re a best-in-class healthcare operation or healthcare system with our operations. If that happens, Symplr’s corporate outcomes involve a ton of different options, but that’s how we think about driving business.

Do you have any final thoughts?

It’s funny that probably 90% of the folks today are using a Symplr product and may not know it because we’ve grown through acquisition of brands like Cactus, API, TractManager, HealthcareSource, and ComplyTrack. We have all these wonderful point products that for years were best-of-breed in each of the categories they served. What we’ve now done at Symplr is to begin to stitch them together and create common workflows across systems, a common look and feel, and interoperability, We are making game-changing operational improvements. 

I would encourage folks to come talk to the business and come talk to Symplr to learn a little bit more how we can benefit them, because it’s probably not the same collection of point products that they once knew. There’s meaningful value to be had.

HIStalk Interviews Sonny Hyare, MD, CEO, ReMedi Health Solutions

Sonny Hyare, MD is CEO of ReMedi Health Solutions of Houston, TX.

Tell me about yourself and the company.

I was born and raised in Houston, Texas. I did my undergrad degree in Europe and then started medical school. I finished up my medical training in Chicago. I’ve been in the EHR space for about 11 years now. I worked for some pretty big consulting companies through 2017 and then started ReMedi Health Solutions, so we are five years in now.

What post-pandemic changes are you seeing with the company and its customers?

When the pandemic hit, we saw everything change, either going virtual or shutting down certain aspects of what was happening in the hospitals. Rightfully so, because of everything that was happening, especially with some of our clients in the Northeast that were being hit with COVID a lot harder than we were down south at that time. What I saw was quick adoption of tools that already existed. I didn’t see anything new come up. I just saw a bunch of people take platforms or technology stacks, put them together, and create what they needed. 

Post-pandemic, we assumed that we would have a hybrid model, or even not going back at all to what the norm had been. But I feel like we are getting more back to normal than we had originally anticipated. Some of the workforce wants to be back in the office. They’re trying to get out of the space that they’ve been in for the last 18 months. People are also seeing a different type of productivity versus at home or in the office.

Many health systems are operating under a budget that was created during the pandemic’s bleakest times. Are they reconsidering their priorities or just making it up as they go?

A little bit of both. They were making it up as they went, but now I l feel like the budgets are coming back into the plans they originally had. It is all coming back as if it hadn’t taken that 12- to 16-month pause.

How do you combine the value of a remote go-live with the benefit of having people wandering the halls looking for puzzled or frustrated clinicians who probably won’t open a help desk ticket?

That’s one reason that our virtual model includes a live video feed. It gives the feeling that somebody is there. But your example is why we need some folks to be on ground. We need this hybrid model to engage the physician who we won’t find sitting on a computer or being in a newsfeed, where you could see frustration in any end user. The live feed makes sure that we maintain that emotional connection, but you could have five tablets with one resource supporting all five of those clinics at the same time. The support model will definitely change post-pandemic, and instead of bringing 1,000 resources, you figure out how to bring in a hybrid model of on-site versus remote.

Are you seeing health systems that are worried less about physician EHR satisfaction and instead see the EHR as a way to implement corporate decisions that may take away individual physician choice?

I do see it, but I’m also seeing  more physicians getting involved in the administrative side of things, making sure that the right decisions are made for the physicians. That was one of the reasons we came about — we essentially understood both sides of the playing field. It was our job to be that liaison, to help the physicians understand why these decisions were being made from an administrative level. Then on the flip side, help explain to the administrative side of things of why physicians needed certain things.

It is getting harder for physicians to what they need, but it’s also getting more complicated on the IT side as well, where you see both sides of the story.

Are you seeing physician EHR dissatisfaction that is driven by local implementation decisions rather than core product design?

That definitely is one of the reasons. Sometimes what I see, and have seen in the past, is having the knowledge of what the tool can do and how it can drive the efficiency that we are all trying to achieve. Sometimes it starts as simply as that. We’ve seen this across the board. You don’t know what you don’t know. Physicians who I’ve known and worked with have dug into these systems over the last decade and could probably answer any question that a physician might have on what and how they need to do something. They have the inefficiencies in both ways.

When we talk about certain changes, we know there’s a lot that goes behind getting something changed like that. Nine out of 10 times, the physicians will be satisfied, but they just don’t know how to do it. That comes back to, are we talking about training, or upgrades, or new additions? These systems have the capability of doing a lot more than the way the physicians are using them now.

Health systems have said in various recent KLAS reports that they wish their software vendors would take a more active role in telling them how to implement and optimize their systems. Are you seeing more demand for a prescriptive approach that takes advantage of broad vendor experience?

Absolutely, and it makes sense. Why would we not explain these certain milestones or scenarios in the implementation in a better way? We were working with a client 18 months prior to them hitting the switch on the EHR that they had selected. The EHR vendor had a list of items that they were going to run through, but at the end of the day, there was no explanation or details in what needed to be done. Some of these bullet points were engagements that would have taken one or even two months. That is misleading the client.

The consulting company and the EHR vendor have to help them guide and understand the decisions that they are making to maximize satisfaction as a whole for everyone. Not only the end users, but the people who made the decision to bring that EHR vendor in.

Are metrics used to identify users who are struggling or functions that aren’t being used optimally?

We live in a data-driven world. Every metric and every data point that we can grab helps us make a better decision. It helps us explain to our clients, as well as to the vendors, why and how this is happening and how we can mitigate the issue. I don’t look at it as a ticket, but something more detailed than that, that has helped us get success. We have to collect information from one-on-one sessions and at-the-elbow support to get a bird’s eye view and understanding of what’s actually happening.

What changes do you expect to see in the company and in the industry over the next 3-5 years?

Three to five years ago, I thought all of this implementation and conversion activity was going to end. But it seems to be constant due to mergers and acquisitions and systems deciding to replace or upgrade software. We may see the same types of engagements in 3-5 years that we are seeing now. I only hope that we are getting better and better as a whole, the EHR vendors, the hospital organizations, and the consulting companies. How can we make this process better for the actual end users who are going to be using these systems on a daily basis? Can we get rid of the term physician burnout?

Do you have any final thoughts?

We are thankful where we’ve gotten to over the last five years. We’re thankful for all our clients that have trusted us. We are still working with our first client, all the way until our last client. Our firm appreciates that, knowing that we’re giving the value that we said we would. For that, we are thankful for the hospitals that took a chance on us.

HIStalk Interviews Richard Caplin, CEO, The HCI Group

Richard “Ricky” Caplin is CEO of The HCI Group of Jacksonville, FL and CEO of healthcare and life sciences of Tech Mahindra of Pune, India.

Tell me about yourself and the company.

I’m married to Danielle and we have three children — Callie is eight, Rilen is six, and Brooks is three. I started the company 12 years ago at the height of Meaningful Use. We began in strategy implementation and training on electronic health records. We grew to be one of the largest firms in our space. 

I sold the company about four and a half years ago to Tech Mahindra. which is a leading firm in the digital transformation and managed services space. At the time we sold it, we were about 1,000 employees plus a bunch of contractors. The idea was that we could bring their services and use our domain expertise and clients. We have done that successfully. We are one of the largest consulting firms in healthcare. We still do a lot of implementation and strategic roadmaps, but it’s more project-based work or large-scale managed services. As a matter of fact, we just closed one of the largest managed services deals ever in the application space. 

We also do a lot in the digital transformation space, such as robotic process automation and digital charters. We do automation as a service. We have launched a new company called HealthNxt, which is an enterprise-wide virtual health platform. So we started in the strategy and implementation space and today we are known as one of the leading innovation and visual transformations firms in healthcare. At the end of last year, ISG, Forrester, and Black Book all had us at the top in innovation and digital transformation categories.

What do you think will change with whatever the post-pandemic normal looks like?

I think we have already started to see change, both in health systems and in big cities. You might have had 500 employees in your IT organization in New York City, Chicago, or San Francisco, and all of a sudden you went virtual overnight. A lot of those people are never moving back into the cities and the office space isn’t needed. I have talked to many organizations that are working on new design layouts that are more of a hoteling system with innovation and collaboration space.

Once you have a relationship with someone, it’s a lot easier to conduct virtually. But still, as you are hiring new employees, you need to build that rapport and chemistry. People are emphasizing that team-building aspect in the way they are laying out their office space. But it also changes the way you pay your employees and where you recruit from. You can be in New York City and hire someone in Mobile, Alabama, so it is readjusting the entire pay school for people in big cities and small cities since all of a sudden you’re in a more national and even international hiring environment.

The way we work and interact day to day are also changing. When you look at how healthcare is being delivered, there’s all of a sudden a window to do things that really hadn’t been focused on before. A lot of organizations didn’t have digital charters and roadmaps, and all of a sudden that’s the way of the future. You are seeing huge upticks in telemedicine, and while we know it is coming down some, there will be a new normal. You’ve seen organizations do remote patient monitoring. We’re going to see a lot of stuff around virtual hospitals and eICU. A lot of organizations are focused on their digital front doors and you are seeing that in the way healthcare is delivered. Health systems are becoming more like technology companies first, and they have to be to compete in the new world.

You offer a fixed-price digital transformation strategy. What results are you seeing?

The first category is the operations of an organization and how they can do things more efficiently. What processes can be automated? There is a lot of opportunity in HR, payroll, revenue cycle, and even facilities and maintenance to automate processes and run more efficiently.

Beyond doing things better and cheaper, you look at the delivery of healthcare. What does your current landscape look like? Organizations may be using multiple telemedicine platforms or may not be doing remote patient monitoring, or if they are, only for a very specific use case or two. A lot of them got into it around COVID, but there’s so many different disease states with use cases for remote patient monitoring. Very few use virtual hospital, eICU, or virtual physical therapy. Many organizations are just starting the journey of deciding what their digital front door will look like and how they will engage with consumers outside the walls of the hospital. That’s a huge part of the strategy.

How are you seeing health systems using robotic process automation and what benefits are they realizing?

I’ll give you a basic example. When you are onboarding a new employee, you may have a bunch of paperwork that needs to be done. You may need several approval signatures. That’s a lot of manual work and a lot of processes. You’ve got orientation, things like that. You might have seven, eight, maybe even more people who touch that process and it takes up a big piece of their time. There’s a lot of paperwork and approvals moving back and forth. If you can automate that process from start to finish, where humans don’t need to even touch it but instead maybe click on an approval button when it pops up, things will be done faster, cheaper, and more efficiently.

That’s a basic example. But think about any process where people are involved — especially things like revenue cycle and facilities – and the size of some of these hospitals and health systems. You have many people monitoring and touching their electrical and lighting facilities, and a lot of those processes now can be automated as well.

Outside of healthcare, I’ve had a conversation with the CIO of the state of Florida, which has a budget of about $100 billion. He gave me an astounding number. He thinks that through automation, we can take something in the neighborhood of 30% out of our state budget. I also got together with a gentleman who is running for mayor of New York City, Andrew Yang. He’s a former presidential candidate. I had dinner with him last Friday, and we talked about the city’s permitting process. For anyone who has dealt with big government, how long does that take and how many people have been doing it for years? You can automate that entire process. Andrew Yang thinks there’s significant savings, similar to the state of Florida, that could be achieved in big government.

We have always had screen-scraping tools and basic automation tools. What has changed from a technology perspective to suddenly make RPA a hot topic?

That’s a really good question. I’m not an expert by any stretch of the imagination, but from my high-level view of what’s possible now, I think there’s a willingness for organizations to try it out. You have a lot more automation companies as well. There’s a whole bunch of them that have emerged and grown. The technology is advanced and there’s tons of applicability. We are winning some of these large-scale managed service projects, but a big piece of what we’re doing isn’t just the labor arbitrage, it’s the process transformation. We are taking a forward bet on what we will be able to automate.

How do you see health system C-suite roles changing now that chief digital officers and chief experience officers are joining CIOs?

We looked at the transformation over the past five or 10 years. The CIO has become a much more important executive role, really one of the leading executive roles in any senior leadership team. Technology touches everything. But now we are seeing the same thing occur, where this consumerism that you talked about, or this chief digital officer role, is driving everything. It’s a strategic role, it’s an operational role, and you have technology. So you will see one of two things happen. The CIO is either going to become a functional role reporting to the chief digital officer, or chief information officers are going to evolve into chief digital officers and they are going to own IT. But it’s a more strategic role where IT is a component of the digital strategy.

Health systems are outsourcing their IT work to offshore firms and in some cases to Optum. What trend do you see?

I think you hit on this earlier. There may have been some movements earlier in automation, but now you are seeing a much bigger uptick. The majority of technology has migrated to the cloud and it is more readily available. I think you will see a permanent shift in large-scale managed services or outsourcing. COVID shed light on that. Organizations had new pressure to decrease operating expenses and run more efficiently, and you saw a big uptick in these large-scale projects.

We won a couple of large deals. We’ve been able to save organizations in excess of 30% of their operating costs while giving them a better service level agreement than they were doing internally. As I speak to CFOs and CEOs — not just CIOs — they don’t want to be in the business of commodity IT. They want to be in the business of delivering world-class healthcare. It has been proven by from organizations like ours and others that you mentioned that the savings is there, and if we can deliver a high-quality product, there’s no reason for them to go back to want to run IT, especially with the pace that technology is involving.

You can’t keep up with some of the things that are happening with cloud. With the cybersecurity risk, it may not be the best thing for you to do. You may want a partner that has a balance sheet that’s going to own those processes, even just from a de-risking standpoint. But I think the pace of change, the amount of risk, and the opportunity for savings are all permanent changes that we didn’t see before. The adoption of technology in 10 years has been tremendous. I don’t think a lot of that will go back. We will see more and more of it.

Do you have any final thoughts?

It’s going to be exciting to watch. Tech Mahindra is positioned very nicely to be a leader. We are hopefully going to continue to grow our managed services business and deliver value, but we are also all in on being a digital leader and with our virtual health platform HealthNxt, which I see becoming one of the largest platforms in this space. Time will tell. COVID served as a catalyst, where we saw a lot of innovation happen in one year that might have otherwise taken multiple years, and that will continue. As the new normal comes back, technology is going to lead the way in how we deliver healthcare.

HIStalk Interviews John Gannon, CEO, Blue Spark Technologies

John Gannon, MBA is president and CEO of Blue Spark Technologies of Westlake, OH.

Tell me about yourself and the company.

I’m CEO of Blue Spark. I have been here for about 10 years. I am an aerospace engineer by training and have spent time in banking and venture capital. 

Blue Spark is a medical device company. Our primary product is TempTraq, which is a wearable, continuous temperature monitor that is designed for patients in clinical settings or remote patient monitoring environments. It’s an FDA-cleared device that is used by pharmaceutical companies and hospitals for early detection of fever.

What is the clinical value of having a patient’s temperature continuously monitored?

Temperature is the only vital sign that is not continuously monitored outside the intensive care unit phase. Temperature taking has been done globally the same way for about 150 years. It is done intermittently, taking the temperature once every four hours. In a number of disease states, patients deteriorate more quickly than within that four-hour window. That is where TempTraq plays a role, such as in oncology, where you have immunocompromised patients, or post-surgery where you are looking for infection, sepsis, or infectious disease.

The American Society of Clinical Oncology’s guideline for the US is that neutropenic fever should be treated within one hour, but they still only take their temperature once every four hours. The benefit of doing something continuously, as is done with pulse oximetry and blood pressure, is that identifying that fever early allows you to intervene sooner.

How does integration with other systems work, such as turning the stream of temperature data into something actionable?

We have designed the system to feed data into an electronic health record. EHRs are records of truth, but that is “records” as opposed to “monitoring devices.” We have a HIPAA-compliant cloud architecture called TempTraq Connect. We provide the hospital with a dashboard for real-time monitoring that can monitor either inpatients or those in remote settings, or we can push that information to their own internal systems. For example, it can go into an EHR, but we’re bringing a process live now where we are pushing data to the Vocera badging system so that nurses who are specifically aligned to rooms are getting actionable data in real time. It’s a flexible system.

What is the task management that is involved in changing a patient’s disposable patch?

Doctors we talked to at the outset of the design cycle asked for two features. The patch needs to be uniquely identifiable so you can associate a dataset with a unique ID, and then further associate that with a patient. Second is disposability. We are measuring the axillary temperature of an infectious disease patient for up to 72 hours. They don’t want to sterilize that device.

We have two versions that we sell into the hospital setting. We have a one-time use, 24-hour device and a one-time use, 72-hour device. When it’s done, you dispose of the device. The system will give you an alert 30 minutes before the end of its run time that it’s time to change that patch.

Is battery life the life-limiting factor?

Interestingly, it is not. It was a surprise in the development cycle that one of the more difficult things to get right was the adhesive. We wanted FDA clearance for all ages, which we have. We use a very gentle adhesive that is silicone gel based. That allows us to use that patch on all ages. But at the same time, we found that, particularly in adult patients wearing the 72-hour patch, the very gentle adhesive drives the end of life at 72 hours from both a hygiene and adhesive perspective. We certainly could design a patch that would run longer based on that battery, but the adhesive and hygienics were the limiting factors we found in our clinical studies.

What does the connectivity to the patch look like?

We use Bluetooth Low Energy. We are sending that signal in a hospital setting to a Bluetooth gateway that we install. It is specifically listening for TempTraq devices. That data is sent back to TempTraq Connect, our HIPAA-compliant cloud. For patients in an outpatient setting, they download our patient application to their device or use a device that is provided by the hospital or the pharmaceutical company that is running that software. Then the same thing happens to data. Once it gets Bluetooth from the patch to the phone, it is transmitted to TempTraq Connect.

Some consumer wearables, such as the Oura Ring, can measure temperature. How good is the reliability and accuracy of those devices versus TempTraq, where you had to prove your capabilities to the FDA?

The FDA is very prescriptive in terms of what is required to use a device as a clinical thermometer, which is the category we are in. FDA requires being compliant with the ASTM E1112 standard, which is plus or minus 0.1 degree Celsius within body temperature range. Beyond that, we also did clinical studies to show accuracy. We did our gold standard test at the Cleveland Clinic, where they were comparing TempTraq to readings from a pulmonary artery catheter in the chamber of the heart. The concluding statement of that study was that TempTraq was in agreement with core. Beyond what the FDA requires in terms of testing for submission, we also did human testing to show that that validation occurred on patients.

We’re seen a wide pandemic rollout of thermometer guns and walk-through fever-detecting frames that seem to offer limited accuracy and usefulness. Does that make people wary that devices like yours can actually work?

I think we’ve all had the experience of somebody using a gun and measuring our temperature at 94 degrees or something like that, hoping that it is still consistent with life. We are conscious that they have been used widely and are fairly erratic. We don’t generally run into those types of devices in the clinical setting, which is our primary market, so we don’t really view those as competitive devices. We make sure that people are familiar with the clinical studies and the standardized testing that we’ve done.

The “normal” temperature of people isn’t always the same 37 degrees Celsius. Is the change in someone’s temperature as important as its value at any given snapshot of time?

Absolutely. It has been studied over time that fever profiles across disease states have a distinctive footprint. The point that you made is a really important one, which is that 37 degrees Celsius or 98.6 degrees Fahrenheit is widely considered normal. But long, large studies have found that someone’s normal can have a standard deviation of plus or minus one degree Fahrenheit. Having a baseline and being able to look at trend data can absolutely be valuable when you are working with patients.

Is the future of the company always going to be related to temperature monitoring, or does your experience with patch technology provide more opportunities?

We view TempTraq as a platform. We have developed an unique database of continuous temperature data. Given the fact that there isn’t a lot of continuous temperature monitoring done outside of an intensive care unit, that makes that data more interesting.

We are looking at two areas of expansion. One is work that we are doing relative to being predictive around early warning. We have engaged with Adam Perer, PhD at Carnegie Mellon University to help us work on doing some of the artificial intelligence work around our network.

The other is looking at moving from univariate to multivariate, taking additional sensors and sensor readings into our database to help with that early warning score concept. But the other is looking at additional devices. We have a unique form factor in the TempTraq device. We will be looking at adding additional sensors to it, likely with a different device because the placement in the axilla under the arm, for example, is not a location that you would typically monitor another vital sign. So to do it effectively, we are probably looking a second device where we could bring in data from another vital sign.

Do you have any final thoughts?

It has been a really interesting year. If you go back 15 months, remote patient monitoring and telehealth were on the horizon, but hadn’t taken a foothold in the healthcare industry. COVID certainly has accelerated that. We have seen a breakdown of regulation to allow telehealth acceptance. We have seen a greater healthcare provider acceptance of telehealth. With that acknowledgement, there is a need to do remote patient monitoring. Not just temperature, but across all the vital signs. A lot of hospitals that we are engaged with today have initiated remote patient monitoring strategies, and we are hoping to work with them as they think through what that will look like.

There is a whole continuum of possibilities across different patient populations. We are an element of that, but it is certainly a multifaceted array of sensors that are being looked at to see what particular patient populations are most effectively tracked in the home setting. If you think about remote patient monitoring, going back a year, it really was around population health and chronic care, and now it is accelerating into the acute care setting. That is important for patients and important for overall healthcare cost. It’s an interesting time to be part of it.

HIStalk Interviews Stephen Gorman, CEO, RCxRules

Stephen Gorman is CEO of RCxRules of Burlington, VT.

Tell me about yourself and the company.

Like many people in this industry, I’ve spent my entire career in the healthcare IT space. I started out working at IDX in the early ‘90s when I was 24, which now seems like a long time ago. I held various leadership positions at IDX and GE Healthcare before joining forces with revenue cycle experts from a longtime IDX customer to start RCxRules back in 2010.

RCxRules helps medical groups improve their billing and coding, which is admittedly a pretty crowded market. There are a couple of things that make RCxRules unique. The first is that our technology focuses on harnessing our customers’ deep understanding of their unique billing and coding challenges. We then take that expertise and help them automate as much of their billing and coding process as possible.

We also have a deep appreciation for just how challenging the healthcare industry is. We appreciate that successful IT projects require a real partnership with our customers to be successful. We pride ourselves on rolling up our sleeves and working closely with our customers to deliver a solution that really meets their needs.

To what extent are provider organizations using customizable rules for billing?

The short answer is customized rules are used all the time. When we started RCxRules, we incorrectly believed our customers would find our “standard” billing rules and guidelines to be most valuable. We quickly learned it was our ability to easily create custom rules that customers appreciated the most.

As we dug into this, it made sense. With the adoption of EMRs, doctors are now entering the billing information directly into these systems, and we all know doctors are not billers or coders. In the old days, doctors scribbled markings on paper charge slips to indicate billing information. Billers then performed the very valuable but underappreciated work of translating that charge slip into a set of billing codes that insurance companies would accept. The billers eventually learned the idiosyncrasies of the doctors they supported and intuitively corrected their specific issues. They provided a great deal more value than simple data entry.

To make this process work well in the current electronic and EMR-centric world, our technology had to harness the knowledge of these billers. We learned that our technology had to be flexible enough to deal with physicians’ idiosyncrasies, and that a one-size-fits-all approach doesn’t meet the customers’ needs.

What billing challenges have resulted from expanded telehealth volume?

While expanding telehealth was a great move for both patients and providers, it really wreaked havoc on the billing process, especially back in April and May of 2020 when CMS and other payers were scrambling to liberalize the use of telehealth. Pre-pandemic, medical groups needed to use certain codes and modifiers to designate a telehealth visit, and these codes were designed to downgrade the reimbursement rate. A critical aspect of the telehealth expansion was normalizing the reimbursement with traditional face-to-face visits. So literally overnight, the payers then wanted different codes and modifiers to reflect that the care was being provided via telehealth, but that the visit qualified for normal reimbursement levels.

Telehealth billing is still complicated, especially with different payers having different policies, and our product helps manage this complexity. But at least now the guidelines aren’t changing every week as they were back in the spring of last year. The next big challenge is going to come when the public health emergency ends and the payers establish their long-term policies for telehealth.

What technologies and processes, especially those involving physicians, are needed to successfully move to value-based reimbursement?

In some respects, moving to value-based care models is extraordinarily challenging. But the concept is pretty simple. Value-based care models focus on compensating physicians for spending the right amount of time with their patients to deliver the necessary care. Sicker patients need more care and attention, and therefore money more to treat. At its core, this is an intuitive concept that allows physicians to get off the fee-for-service treadmill and allocate time based on clinical need.

This simple concept becomes very challenging in a few ways. The first being that physicians have to live in two worlds, fee-for-service and value-based models, which have different incentives and drive different behavior. The second is the actuarial-like accounting and reporting that is necessary to allocate the right amount of money to groups based on the health of their patients. This is where HCC coding comes in. Older and sicker patients cost more to care for than younger and healthier patients. Again, it is an easy concept to grasp, but the devil is definitely in the details.

The bottom line is that the physicians need help succeeding in this new model. The staffing profile and technology that are optimized for fee-for-service don’t work in value-based models. The physicians need help clinically and administratively. Clinically, they need to staff care teams that can support both physicians and patients, and they need data on which patients need the most care. They can get this data either from their own population health solution or from their payers. Administratively, the priority is utilizing HCC coders and HCC technology to ensure the physicians’ good work with patients is correctly reported to the payers so the right amount of money is allocated for care.

What are the company’s priorities over the next 3-5 years?

Our customers are large medical groups. We fully appreciate the challenge they are living through balancing the fee-for-service world with the value-based care world. It’s the proverbial “foot in two canoes” challenge. Most medical groups have more priorities they want to accomplish in any given year than resources to get them done. They sometimes talk of feeling like they’re on a treadmill that keeps speeding up every year.

Our focus over the next three to five years will be the same as our focus over the last 10: helping customers get off that treadmill. We will continue to build and deliver solutions that remove as much manual effort from this complex billing and coding process as possible. We want to free up our customers’ time so they can accomplish more of their priorities.

HIStalk Interviews Carina Edwards, CEO, Quil Health

Carina Edwards, MBA is CEO of Quil Health of Philadelphia, PA.

Tell me about yourself and the company.

I have spent my career leveraging technology to improve the clinical and patient experience across healthcare. I’ve done that at companies including Imprivata, Nuance, Zynx Health, and Philips Health.

Quil is a digital health joint venture between Comcast NBCUniversal and Independence Blue Cross. We are on a mission to help people organize and navigate their health lives. We have proven that an educated and engaged consumer leads to better outcomes at a lower cost. That has been the holy grail and we want to see that through. It’s an exciting venture and I am thrilled to be at the helm.

To what extend has widespread availability of consumer technology, as well as comfort with using it, provided richer healthcare at home options?

The home as the center of care is squarely in our remit. We purposely think about the connected home, which with devices, wearables, and the television hanging on your wall, can be truly differentiated and activated in health. But the core comes down to, why aren’t consumers activating in their health?

One of the big things for me is that we need to stop, as an industry, thinking about the patient, the member, the employee, and the caregiver. We need to start thinking about the person. We need to be thinking through how we bring health and the navigation of health together for the individual. That means meeting them where they are — whether they are in a high-tech or low-tech household, whether they are connected, how they are connected — and trying to figure out the best way to activate that persona in a healthcare journey or in health literacy.

Nobody wakes up hoping to be admitted to a hospital or nursing home. Is it hard to tell the story of care options that don’t involve particular venues?

That’s the part that is rapidly changing. My customers span providers, payers, and employers. When I speak to all of them, they see their as-is state moving very quickly. The more progressive ones get it. The hospital at home concept has been touted for a very long time, but COVID brought to life the need to do infusions at home and do cancer treatment at home. Nobody wants to come in to the city center to the amazing, beautiful, big cancer tower, because that’s inconvenient for their life and they are already in pain and struggling. 

How do we bring as many services, knowing that there is a huge cost implication of that, too? Where we can leverage people, process and technology, we can rethink many things at a lower cost and meet people where they are. I love that sentiment.

How will health systems change their business model as the pandemic winds down leaving deeper experience with delivering care outside the hospital?

Everybody realized that, and they quickly spun up the technologies. It’s an interesting perspective where both providers and payers realized where the gaps were in the other side of the pane of glass. It wasn’t so much, can I get and engage my patient, member, or employee on a digital medium? It’ more like, how does it fit into the workflow of healthcare as we’ve established it? How does that integrate to make sure that the waiting room is virtual? The thoughts are virtual? You’re keeping people engaged, you’re meeting them, and they’re not meeting some random doctor or someone that doesn’t have their health history.

As they look forward, we hear a lot about, how do you bring information sharing? Now that we are all working towards interoperability with the passage of the legislation and the activation of the legislation, how do you bring that to the pane of glass in the provider workflow? In the patient workflow? So they they can not only interact, but they know what to do pre and post, because so much is forgotten during the encounter.

That’s another stat that I love to bring to people’s attention. People forget that when you hear a critical diagnosis or even a joyful diagnosis – congratulations, you’re pregnant, or I’m sorry to inform you that you have cancer — your brain goes to a whole different place. Studies have observed time and time again that patients can’t easily recall information that was relayed during an appointment. So now in this new medium, how do you make sure they understand, acknowledge, and can continue learning and engaging post the video visit?

What expectations come with the big investments that are being made in healthcare companies that offer everything from primary care chains to employee wellness technologies?

It’s an interesting world and I’m really encouraged by it. You’re going to see a lot of starts and stops, and we’re going to get to new models because consumerism is creeping in. 

The excitement is around consumers and where we’re trying to meet people where they are. We are trying to segment the market. There isn’t one size fits all for an individual, what they need, and their health at a certain part of their life. If I am a younger employee trying to figure out basic care and navigation, things like needing to get a flu shot, that’s a very different patient persona than someone who has been given a new diagnosis, is dealing with a chronic condition, is aging, or needs to go in for a procedure. Care at that point in time becomes very local.

I love that these new models of care are springing up. Just like there’s not one department store we buy clothes in, and there’s not one TV channel that we consume information on, we are giving people opportunities to engage in mediums that might work for them, make it easier in their life, and get all of us to better outcomes. I’m encouraged by it. But I don’t think there’s one big magic bullet that will change healthcare as we know it. At the end of the day, complex care requires care coordination, testing, and all those diagnostic tools that hopefully will move over time into the home. But those towers will still be relevant in someone’s health journey over time.

How do you broaden the use of apps, wearables, or other technologies beyond the “worried well” to more effectively move the health cost needle?

We spend a lot of time thinking about care in the home — ambient sensing,  wearables, technology, and voice. Together with our parent Comcast, we’ve run a bunch of experiments, especially with the silver tsunami that is coming, the aging at home of a generation that I adore that wants to go out fighting. They do not want to go to assisted living facilities. They want to live exactly where they are and how they want to. We have done a lot of consumer research where those who are aging at home will sometimes buy some of these technologies to allow them to continue to live independently. The other thing that we see is that there are 54 million unpaid caregivers in the US, those unpaid caregivers are also managing their own lives, and 23% of them have worse health because of their caregiving responsibilities.

Finding technologies to support the care recipient and being mindful of the individual that wants that independence, but also wants that safety net, is a great segment where you will see consumerism come to life for aging and home solutions that are way better than the “I’ve fallen and I can’t get up” button. That’s where you are going to see some really fun innovation.

Some people dumb down hospital at home and remote monitoring to “can get a pulse ox into the chart?” That’s not the challenging part. It’s the figuring out what data to get, what ranges to allow, and how to make sure that when it comes into the clinical record that it’s clinically relevant. How do you start thinking through the lens of the clinicians at that point in time to say, what is useful in an encounter? What is useful for me to remote monitor? When do I actually look at thresholds, alerts, and alarms?

That remote patient monitoring world will continue to scale from simple wearables to ambient sensors. We have been playing with this concept of, can you make the bathmat a scale? Can you start using new technologies for those that are very chronically ill, that might have episodes that they might not be self-aware enough to tackle?

A new article just concluded that nurses spend twice as much time managing a patient who is seen virtually instead of in the office, mostly because they need to monitor a steady stream of data from wearables and patient-reported information instead of just looking everything over during a three-month office visit. Has the capability of sensors exceeded the ability of people or systems to monitor the data those sensors create?

It’s a workflow and insight challenge. When you start looking at data, data is data. Data is overwhelming. You can start gleaning insight from data through models, algorithms, and deep understanding, but you have to do so through the lens not just of the data and the individual generating it, but the individual who has to consume the data. We spend a lot of time on user experience and user design, and sitting with clinicians – which has been challenging during the pandemic – to observe their workflow, watch these things, and design the system around when it should alert, when it  should tell you, what’s overwhelming, what can be computer screened out, and what can be noise in the system. Then, what is actionable, and where does that action lie?

When we redesigned these versions, the process side of it, we try to throw tech at a lot of things. The process and understanding side is important. Then, there’s the financial component. Is the nurse doing some of those things because that is the right data digestion, or is it also because there is a documentation requirement to get reimbursed for remote patient monitoring? Thinking about that whole spectrum and making it a win-win for all three parties involved is key. The payer truly comes into this as well. It’s a new frontier that can only be better. When we start any new technology, it changes. When it moves the cheese, it changes the workflow, and so many times we don’t assess the workflow change and acknowledge it.

With all of the provider roles, who coordinates monitoring the patient’s data that is created by devices in the home?

The key for us is today, where we are. This is all a life cycle, and as we are progressing down our life cycle. We see convergence coming together for the individual. That’s our three- to five-year vision of how I, as an individual, get the different streams of health, care, benefits, and employee benefits all navigated for me in one pane of glass that I choose. We’re starting in the provider, payer, and employer world, with unique use cases. Learning and aggregating, and where we can collapse them, we do. If I am on a pregnancy journey that is navigating me — not just on benefits, short-term disability, talking to my manager about being pregnant, and thinking about childcare post delivery — and I am also on a pregnancy journey with my provider, those two worlds come together for me today on a pane of glass.

But each of those pieces is uniquely owned by the organization. The employee benefit side of it is going back to the employer. The clinical insight generator is going over to the provider. But the individual has one pane of glass to see the experience together. That is the nirvana as we think through data sharing, permissioning, and where all of that needs to go. And to your point, who is bearing risk on that? How do I make sure that the risk-bearing entity — because there’s many models of risk now — that you need to align around that model of who’s there in it with you, that everybody wants the best outcome? Then, who is incented for better outcomes?

Is it hard to sell an employer an app or service using metrics around employee adoption or satisfaction rather than cost savings that will deliver return on investment?

Is it difficult? No. Do you have to understand their world? Yes. All employers want the best outcomes for their employees. There are more forward-thinking ones in benefits and benefits aggregation that are thinking through better outcomes, getting people to higher-quality venues, because that’s a win-win for everybody. It’s not wasting time, and it’s keeping presenteeism. There are so many ways to measure success.

But to your point, the more progressive employers are looking for real, tangible outcomes. It’s not just about X percent engaged, X percent liked it. Clearly, there’s a point that you want a great employee experience. It has to be usable. Those are almost table stakes today. How, though, do you generate that longer-term ROI that justifies that? Who do you put in the middle of that? We have taken the approach where we are going to be focused on a digitally-forward health engagement platform, not coach-enabled. But others have taken the approach where we are coach enabled, and then through digital interaction, we can get you to a next action. We will see that evolve over time. Can we get more digitally forward so we can scale and improve outcomes across the continuum?

How can technology support unpaid caregivers of people aging at home?

I look at it pretty simply. It’s there for them and it’s there for you. For them, it’s technology that is easing the care recipient’s mind. For you, it’s also there for the caregiver. They are able to do task trade-offs with their family, coordinate things, be in one space, not have to time slice, and have one point of view on what’s going on with mom, dad, loved one, neighbor, etc. There’s also levels of caregiving. The fun thing is there for them, there for you. As the care recipient, there for me, I want to know who has access to my data, who I want to have permission to my data. 

We think a lot about the tier of caregiver you are. If you are the neighbor who might have a key to get somebody in if something happens to you, that’s a tier one relationship. If you’re navigating and supporting me for a geriatric hip fracture to home, or through hospice to home, you want that person to have access to everything. Making sure that the tool understands that it’s not one way. It’s not a caregiver tool, it’s the caregiver and the care recipient tool. I’ll leave it with there with there for them and there for you, because it’s multi-sided.

HIStalk Interviews Charles Tuchinda, MD, President, Zynx Health

Charles “Chuck” Tuchinda, MD, MBA is president of Zynx Health, EVP and deputy group head of Hearst Health, and executive chairman of First Databank. Hearst’s healthcare businesses include First Databank, Zynx Health, MCG, Homecare Homebase, and MHK.

Tell me about yourself and your job.

I’m a driven physician who is hell-bent on making healthcare better. I  want to figure out how things work and how to innovate, which applies to many things in my life. This weekend, as a random example, I actually tackled my first brake job and successfully replaced the brake pads on an old car.

I’m the president of Zynx and I still have some responsibility over FDB, and more broadly, additional responsibilities across Hearst Health. Zynx has been on a mission since 1996 to improve the quality, safety, and efficiency of care. We help people make better decisions that lead to better health through evidence. That’s something you see playing out in the world today.

How much of a physician’s decision-making can be directly supported by available evidence, and why does medical practice sometimes fall outside available evidence?

This question will continue to grow in terms of the body of knowledge and the evidence that helps us think about what we need to do. 

Let me come at it a few different ways. When you look at our process of processing evidence and synthesizing it, we search across a bunch of different literature sources and we filter these things based upon the quality of the study, the type of study. Often, we are looking at over 13,000 studies, so we read and distill them and then we grade them and prioritize them. Then we generate a core piece of knowledge that we call Zynx Evidence that helps us as a foundation for all of the clinical decision support that we make.

But if I step back away from our process and I think about healthcare overall, there’s just so much information, or I should say data, that is available now. The challenge as a clinician is that you have to synthesize it. There’s so many competing interests. You are expected to practice and handle a high volume of visits. You’re expected to practice with high quality of care. You are measured on whether you can reduce readmission or shorten the length of stay.

As clinicians, we are expected to draw upon so much data and synthesize it so quickly. That calls out for partners, information, and tools to help you be the best version of yourself, to do the best that a clinician can do. In the future, we are going to see clinical decision support continue to advance, first to support the healthcare professionals and elevate their practice, and in the long run, to elevate and empower the average patient to make the best possible healthcare decision.

People talk about gaps in terms of the knowledge base. There will always be gaps, because there’s a frontier of knowledge out there that is growing and expanding. But we live in an era now when a lot of the healthcare information can be captured, stored, and analyzed, so the body of knowledge is going to continue to grow. That will make it more important to understand what the standard is. What do we already know about how to go about and do things in a better way?

How difficult is it for physicians to assign the proper weight to their personal experience with looking at someone else’s research that covers a large population?

It is challenging. I remember medical school very well. I went to Johns Hopkins and was infused with knowledge around what the research and evidence shows, essentially defining the right standard of care, at least in the eyes of the medical school I went to. Then when I went to the floor and started meeting with patients, trying to help people do what I believed was the right thing, based on the way I was educated. That turned out to be a big challenge, getting people to do what is likely to be in their best interests for better health.

You also see that challenge with clinicians. Clinicians have different experiences. When they graduated from school, there was a certain level of knowledge and a certain practice pattern. The challenge is that clinicians and the patients they see influence what they think is the best way to practice. What’s tough is that there’s always people out there doing more research, studying more people, coming up with better ways.You have to look at that, synthesize it, make sure it’s right, and make sure it’s right for your situation. Then if you are constantly trying to improve yourself, you’re going to want to bring that into your practice and your day to day. That’s a challenge that has been described in the literature as something that takes, unfortunately, a decade plus for some new knowledge, from the time it’s discovered, to be put into practice and benefiting a large population.

It’s tough. And when you look at the differences in care and the disparities, it’s not only about knowing the difference between the standard of care and what actually happened, it’s also a lot about convincing people and changing minds and helping them access and make good choices.

Will the less-structured, more timely way that new research and clinical findings were disseminated during the pandemic influence the distribution of clinical information in the future?

Yes, absolutely. The pandemic highlighted the fact that reliable information is more important than ever. In the early days, you saw that the volume and velocity of information coming out had increased dramatically. Lots of headlines and a lot of observations. There was this urgent need for scientific or rigorous medical knowledge. You also saw public health entities trying to make decisions with the best available information they had at the time.

It was this nexus of, I want some good information, but I don’t know if it’s out there. Then a flood of information with unclear significance. That’s when it’s important to trust your process. Go back, look at the source, look at the study design, try to figure out if it’s rigorous. Once you feel like you have distilled a few things that work, the other challenge is getting it into practice. How do people apply it? How do you implement it into their workflow? The pandemic really highlighted that need. It’s a good and a bad thing.

In the early days of the pandemic, a lot of health systems sent some of their staff home. They became productive, worked on some change management type stuff where they said, hey, I’m home, I might not be able to go in at the moment, but I can work on updating the system, or I can figure out a protocol. In several health systems, we saw that people drove change at a much better and faster rate than ever before. That gives me a lot of hope, because if folks have the right information and are empowered to make a change in their practice patterns, they will.

Implementing standardized order sets was a contentious topic a few years ago. Now that the implementation dust has settled, what is the status and future of order sets?

The order set market has evolved dramatically, and Zynx has evolved to match it. We have been partnering with clients to serve their needs. The classic market, when EHRs were being deployed, was to populate the EHR with a lot of point-of-care CDS, your traditional order set, a tool and a content inside the EHR system. But now as people primarily have EHRs deployed, you see a shift to optimizing the information you have, updating it. That means a greater need for collaboration software to drive your clinical teams to work together, to examine the changes that they think that they should put into place, and to make decisions and track an audit trail. 

Zynx provides tools to help do that. We even have a platform where we can interrogate the configuration of an EHR and compare it to our content library to suggest spots where there might be gaps in care or vice versa, like some extra orders that you don’t really need that might be considered waste. Maybe they shouldn’t be done when you’re an inpatient, they should be done when you’re in clinic or in follow-up afterwards.

The new frontier for us is looking at clinical practice patterns, the actual ways that clinicians are taking care of patients. Our content team has written business logic rules to interpret that order stream and identify opportunities where clinical practice patterns may not match the standard of care or the evidence-based interventional suggestions. Those are things that we want to highlight as a way to drive clinicians to change their behavior and get better results.

What is the value of slicing and dicing the universe of aggregated data to allow physicians to do a “patients like this one” crowdsourcing-type review?

I would say that there is some utility to that, although I don’t know if that would be my go-to source of rigorous information to begin with. 

When I look at that type of guidance, I map it out in a way where I first want to look for any sources from well-known publications, from experts, from sources that I believe are free from bias with good, rigorous study designs and see if they have done their best to control and observe an impact related to an intervention. That is your traditional, solid, core, evidence-based recommendation. The reality is that there’s not an evidence-based recommendation for everything a clinician might do, and then you need to look for other ways to take care of patients and decrease variability. You might look for some expert opinion, and short of that, you might start to look at practice patterns that are aggregated.

The danger of going to practice patterns right away and crowdsourcing an intervention is that you are going to propagate common practice. Common practice presumably is OK, assuming that the common practice was a good thing. But it also then means that people are going to be entrenched where they are. If there was a breakthrough or new discovery, that won’t be common practice. That’s why I wouldn’t say you go to common practice first. You would go to whatever the latest and greatest leading evidence would suggest that’s rigorous, and try to change behavior and try to change clinical practice to that. But short of that, go to the experts, And if you’re completely lost, then I would consider looking at what else have other people done and what we know about this path in terms of helping people out.

How should an expert’s gut feeling about what seems to work be incorporated into more rigorous, evidence-based recommendations?

My hierarchy would start with trying to find evidence-based recommendations that are based on the best studies. Short of that, I would go to experts, because they presumably specialize in it, probably have a comprehensive knowledge of the disease process going on or the treatment protocol. Then the common practice piece I would put below that, because experts are outnumbered by just the number of generalists. My worry is that maybe an expert who has studied this, who does know the cutting-edge stuff, has the better way to do it, but it’s not showing up if you use an algorithm to just source common practice. Then you don’t have anything else to go with, I probably would look pretty hard, before just treating someone willy-nilly, to get a good recommendation.

It makes me think of the “do no harm.” I’d rather make sure that the things I’m suggesting are sensible rather than just suggesting random things, which then might start to fall in the category of waste. It’s a hierarchy that I think most clinicians, when they practice, come into. You saw it play out with the pandemic. We saw some early treatments look like they might be promising. I might even argue that they became common practice for a period of time. Then people studied them and realized, wait, this is no better than placebo. This is not leading to a better outcome. Those practices largely died out.

Artificial intelligence seems to be focused more on diagnosis rather than treatment, probably because the diagnosis endpoint is better defined. Do you see a role for AI in clinical decision support?

I’s really early days on artificial intelligence. I’m a huge fan of artificial intelligence, but I want there to be a lot of rigor in it. I worry a little bit about the hype around the shiny new object and the fact that that might sway people to try things before you really know how well it works.

When I look at AI in healthcare, one of the reasons we see it in the diagnostic area is that AI for imaging, in particular, is quite good. That’s built on a lot of imaging research that came from other industries, and when you apply it to healthcare, we get good results. There are thousands of studies that have been reviewed by humans and labeled appropriately, so when you train an AI system on that type of information, you can get and characterize the way it performs rather well.

When you look into other areas, especially around treatment and around maybe other diseases, it’s harder to know, because you want to have a large body of information to validate it against. This is one of the topics that we track very closely at Zynx and across Hearst Health, because we want to really understand how well an AI algorithm might perform and how you can judge that. Do you judge that by knowing the makeup or the composition of the AI algorithm, the layers of the neural network, or do you judge that by the input data that you gave it? When you look at the input data, do you want to have a diverse population of folks with a lot of differences, or do you want to have something that’s more uniform?

All these things are still not quite answered. We don’t have a great standard to prove that an AI algorithm is rigorous and it needs to work on a population that looks like this. I think we’re going to get there soon. We have that in other areas emerging. When you test new drugs, you want to test it on a specific population. They may vary by age. They maybe vary by comorbidity. We need to be doing that type of rigorous testing on the AI algorithms. It’s early days, so I think we are getting a lot of tools implemented. But I’m hopeful that we’ll come up with a good process and then have really good, reliable tools to use.

What is the status of electronically creating and sharing a patient’s care plan, and the challenge of defining who of potentially several types of caregivers is quarterbacking the patient’s overall care?

We are proud that we were recognized by KLAS as being Best in KLAS this year for order sets and care plans. That’s a great honor, and we were rated very highly across all the categories that KLAS surveyed our clients for. We have over 1,200 clients and it’s growing. These health systems use the order sets and care plans to help their clinicians work more efficiently.

When you look at how it works at the point of care with care plans specifically, we help guide the interdisciplinary team on the assessments and the goals that they should set for each patient based on the disease condition and the severity of illness. Then we help them perform the right interventions, the tasks to drive that patient to heal and to do better.

Our future and our innovation work has been around translating a lot of those care plan items to patients themselves. We think that patients could be engaged in their care, and to some degree, do some self-care. That should be aligned with the care plan from the care team. Some of these interventions seem pretty straightforward, like make sure you show up for an appointment, make sure you assess a certain thing, know the goal that your care team has set for you so that you can follow up on that.

We think that by increasing the engagement and the participation of patients themselves, people get to better outcomes and are able to receive care in different venues, not necessarily only in an acute-care hospital setting. I’m excited about that. That’s a new area for us, where we tie the two together. We are looking forward to building that and seeing where that can lead us.

Do you have any final thoughts?

Practicing medicine is pretty tough today. There are a lot of competing interests between quality and volume and reducing readmissions and shortening length of stay. The challenge for clinicians is they are expected to draw upon more data and synthesize more things than they ever have, so there’s a need for tools.

I see a future where clinical decision support will continue to advance and help professionals elevate their practice. Ultimately this is going to make patients healthier, and we’re going to all benefit from it. I wish it was as easy as replacing my car’s brake pads. I mean, that would be great. But healthcare is complex, and there’s a lot of different things that factor into getting a good outcome. But I’m very hopeful.

HIStalk Interviews David Baiada, CEO, Bayada

David Baiada, MBA is CEO of Bayada Home Health Care of Moorestown, NJ.

Tell me about yourself and the company.

We are going on 50 years as a provider of home-based healthcare services. We are based in the Philadelphia area, in southern New Jersey. The business was started by my dad who, at the age of 27, was an aspiring social entrepreneur before the term really existed. Through mission-centered, people-oriented focus on culture, connectedness, and service, we have — little by little over a long period of time, almost entirely through organic growth — become one of the largest providers in the country, with about 30,000 employees across 24 states and eight countries.

Because of our scale in a quite fragmented industry and our diversity of services, we deliver eight different types of service, depending on where we are in the country or in the world. Our long-term orientation as an entrepreneurial, not-for-profit organization is focused on long-term sustainability and continued growth adaptation to the market. That makes us a little bit different in terms in the ways that we invest in and position ourselves to continue to make an impact in the communities we serve.

What is changing about home health and the involvement of health systems in it?

While the delivery of services in the home is clearly not a new phenomenon, the societal attention and perpetual reflection on safety and health at home has been clearly spotlighted over the last 12 to 14 months. Never has there been a time where literally every single American is staring at the TV every night thinking about, how do I stay safe and healthy in my house? 

That has created a bit of an awakening for the healthcare industry. Maybe we can deliver a high-quality service at scale at a lower cost in the place that people prefer, which is their living room or their home versus an institution, where appropriate. Maybe we can use technology to deliver certain types of services and interventions virtually or by video.

All of these things are not new. We’ve been working in the home for centuries. We have been delivering remote monitoring and virtual care for a decade or more. But the last 14 months clearly have created a bright spotlight on the power and opportunity that exists with the things that we can do in the home.

What impact did the pandemic have on the home care model and on your business?

The most important thing we saw is the validation that these amazing people — nurses, therapists, home health aides, and others who have chosen a profession to take care of people in the community — rose to the occasion. They are used to walking into the unknown, whether it’s COVID-19 or any other type of illness or environment. Clinicians that have chosen this profession rose to the occasion, and it was super inspiring to watch people, when appropriately prepared with PPE and clear protocol, walk into the unknown and navigate whatever was necessary to take care of people, whether it’s the thousands of COVID-positive patients that we took care of or the unknown of what was happening in that home related to risk and potential infection or otherwise.

The business implications were all over the map. The biggest implication is that volumes are up and down for different parts of the country with infection rates. That created, and continues to create, a wet blanket of ambiguity and unpredictability of what might happen tomorrow with protocol and infection risk. Then you compound that with the ambiguity, complexity, and unpredictability of what’s happening in their personal lives, with their kids and families, school, travel, and all these other factors. Ambiguity and unpredictability has been a major force, not just in our organization, but in our lives more broadly.

Does scale help you recruit and retain employees for the hard job of going into the homes of clients, especially given the reimbursement challenges?

We have dealt with cycles of shortages in different labor markets, whether it’s geographic or different types of workforce, for decades. We have now clearly entered a phase where the cycle is no longer a cycle, it’s a perpetual of supply shortage. The demand for our services — along with other macro factors like population, demographics ,and aging – has taken us into a cycle of permanent shortage for all types of in-home care delivery, nursing and home health aides in particular.

We are spending a lot of time, using our scale as you alluded to, to differentiate as an employer, to be more sophisticated in how we find people and how we create opportunity for them. We have a diverse, large organization with lots of different types of services, which creates lots of opportunities for people that are interested in doing new things, trying new settings, and picking up new skills. Our scale helps with that for sure.

But a lot of this is about figuring out how to create an environment in which people feel supported and engaged so that they stay. That really is a part of how we think about this challenge, which again is no longer a cycle. The demand for our services will continue to increasingly outstrip the supply of caregivers for decades, so this is the heart of the matter for us.

What services or technologies could help family members who unexpectedly take on the role of primary caregiver?

Virtual care and remote monitoring are a huge opportunity for family caregivers. It reduces the burden of having to get to a doctor’s appointment and creates the ability to monitor signs and symptoms proactively to avoid risk. There’s lots of incredible technology that is emerging and being adopted more quickly in sophisticated ways for both virtual care and remote monitoring. That’s a huge benefit to the family caregiver.

Another example is what I will bucket as care coordination and transparency tools. We have worked with, and continue to work with, a lot of partners to experiment around how to make it easier for family caregivers to understand what’s going on and why and the interaction of all these different silos in the healthcare system. Everything from scheduling of appointments to messaging with providers to history and medication reconciliation. There’s just so much to manage when you have a sick, at-risk, or vulnerable parent or loved one. If you have ever had to navigate the system, it’s really complex, and some of the technology and tools out there are trying to break down that complexity and simplify it for the family caregiver. I think they are making an impact.

What levels of integration, continuity of care, and accountability are you seeing between hospitals and home care organizations?

It has been emerging for a while, but in the past 18 months and certainly the last 12, the dialog in the health system boardroom around the strategic importance of home and community-based care delivery, the extension of the health system’s brand into the home, the seamlessness of the transition from acute to home — it’s moving way up the strategic priority list. You are seeing a lot of health systems say, we need to be really good at this. Some, to the extreme, are saying, we are going to start reducing inpatient beds over time.

All this is part of a broader shift, too. Payment could unfold over time where health systems are taking on an increasing percentage of the risk dollar, in which case when at risk for total cost of care, they are now properly incentivized to think creatively about how non-acute or less-expensive remote, virtual, and home-based care can help them create better experiences and better outcomes at a lower cost. We have a whole channel, a joint venture of structures with health systems that are designed specifically in this context. How do we jointly own home and then Bayada-managed home-based care delivery capabilities for a health system to give them instant access and continuous innovation around best-in-class, world-class, home-based care?

What new technologies are important to your business?

What I like about what’s happening in the market, and this spotlight on the importance of home-based care in the continuum in an increasing way, is that it is inviting a lot of capital and innovation to the challenges we face.

When we talk about challenges related to health system integration and extension of their capabilities into the home, one of the most fundamental challenges that health systems face — and it has an impact on Bayada as a home-based provider — is how a transition works. How do you coordinate someone’s transition from a hospital bed to their living room and all of the steps and coordination that happens along the way? They may have a stop at a skilled nursing facility. They may need new medications, but they have no transportation to get them. They may need coordination and conversations between multiple specialists.

All these things happen in silos. You are constantly repeating lots of different information to different people in the system. Platforms like Dina’s care-at-home platform and network are trying to create seamless transitional care, and that provides benefits to the patient and their family. They get empowered with an understanding of what’s happening. It has benefits to the health system that is trying to ensure that this person has a path home in a timely way. It has benefits to us as a home-based provider, because we then are empowered with historical information context before we enter the house, which helps us create a better service and keep them safe at home, which then ultimately creates a virtuous cycle because we’re avoiding unnecessary readmission and other types of further risk.

Dina is a great example of solving a complex but straightforward problem. When someone arrives at a hospital, how do you make sure that the transition out of the hospital back to home with any steps in between happens in a way that’s actually productive versus super frustrating?

What impact are you seeing from private equity’s increasing investment in healthcare, especially in home care, long-term care, and hospice care?

Our industry was, for a long time, a textbook definition for a cottage industry — highly fragmented, mostly local and small proprietor-owned or not-for-profit organizations. When sophisticated investment and capital comes into an industry, it usually increases the level of competition, which hopefully means that the services and the quality of services goes up for the patient, for the end user. It’s probably too early to tell about how that impact will play out, but in general it is drawing a lot of attention.

Also, third-party investors, financial sponsors like private equity firms, have a lot of relationships and a lot of credibility. The ability for them to put money to work to innovate, but then also put relationships to work to help ensure that those that control the funding and that control the future of healthcare delivery and regulation have adequate visibility and exposure to the power of home-based care. That’s a benefit. A rising tide raises all boats. This is a huge industry with a lot of people that are vulnerable and need a lot of help, and the more sophisticated, competitive innovation, the better.

What changes do you expect in home care over the next three to five years?

The percentage of healthcare services that can be and will be reimbursed and supported from a regulatory perspective to be delivered in the home will continue to increase meaningfully. That will be empowered by better capabilities from organizations like ours. Better technology that makes this delegation of services more palatable, which would include things like virtual care delivery and telemedicine, et cetera. Then ultimately it will be made possible by regulatory evolution and adequate reimbursement. Home care has been an underfunded segment of the system, and to empower scalability of some of this innovation that will enable increases in home-based care for the appropriate types of services, regulatory and reimbursement structures have to evolve, too.

Ultimately, the outcome is that a higher percentage of services will be delivered in the home than they are today, which ultimately is what’s right for the patients as their preferred setting with better outcomes and lower costs.

HIStalk Interviews Micky Tripathi, National Coordinator for Health IT (Part 2)

Micky Tripathi, PhD, MPP is National Coordinator for Health Information Technology.

FTC recently warned companies and developers about using AI algorithms that are biased, intentionally or not. What government involvement do you expect, if any?

We actually just had a discussion about this yesterday within ONC, starting to talk about that, among a set of issues that are related to health equity. That is certainly a part of it.

I don’t have a great answer right now. We are just at the beginning of it. We are just starting to start to think about what the issues are and what federal agencies have involvement in this. You named a couple in FDA and FTC. I’m sure there are others who aren’t necessarily involved from a regulatory perspective, but could be involved from a use perspective. If you think about CMS using algorithms, VA, DoD, IHS, I mean it certainly could be all over the place with different federal agencies that are involved in healthcare in one way, shape, or form.

Next is the question of, how do we think about bias? There is certainly a piece that is related to help disparities for minoritized, marginalized, underserved communities. That’s a huge piece, one of the things that I was addressing. There are also more general questions of bias. If you think about bias from a statistician’s perspective, it is anything that would bias an inference that one is making using a set of tools. You can imagine, for example, general questions about algorithms that are trained within certain environments. What applicability do they have to other environments, and  what inherent biases are involved in that? How do we measure those or parametrize the learning foundation that a set of algorithms was developed on, and how applicable are they in other circumstances? How do you set some parameters around that to give some assurance that you are addressing as many of those sources of bias that are possible, recognizing that there could be a whole bunch of other ones that are harder to detect?

For example, if we all wanted to move to a world of quality measurement that relies less on structured data elements – which impose a certain burden on providers and provider organizations to standardize that data and to supply that data – and move to a world where that can be complimented by, and perhaps eventually substituted by, a more algorithmic-based approach with more computable types of approaches applied to with natural language processing and other kinds of things, that raises the question of, if the algorithm has been trained to do certain types of detections — let’s say for safety, or is trained to do performance measurement in certain ways – in an environment like the Mayo Clinic or a large set of academic medical centers, is that applicable in other hospital settings? How would one know that it is applicable in some ways? If you are going to start paying people based on the results of that, we are going to have to develop a set of answers to those kinds of questions.

What is ONC’s role in reducing clinician EHR burden?

We have a clinical team that is working closely with CMS on clinician burden. We co-wrote a report that was released at the end of last year. We spend a good amount of time thinking about that with respect to everything that we do, especially as we hear about all of the concerns that people have about health information technology and burdens that have been imposed.

Part of the adoption trajectory is that no technologies are perfect, and the only way to make technologies better is for users to use them. Anything that is designed purely by a set of software engineers without having a good base of users banging away at it and providing that ongoing feedback is not really a reality when you think about the systems that we think of as being the most highly usable. All of those are improved, sometimes dramatically, with the input and the feedback they get from thousands and millions of users. That is true in health IT as well.

So part of that is growing pains, and part of that is things that are imposed on the technologies from the outside. The EHR gets blamed for things that it’s really just the vehicle for, like prior authorization requirements and more documentation requirements. There’s a sense that it’s easy because it’s in the system and is automated, so I have more of it required now than I did in a paper-based world. Users sometimes blame those things on the EHR, when in fact they are being imposed through that vehicle and then pushed through that vehicle separate from the question of the burden imposed by the technology itself.

At the end of the day, it doesn’t matter what the source is. That’s why we spend a fair amount of time worrying about both the technology and usability as well. What is it that we are asking to be forced through that system and are asking users to be able to do?

What will ONC’s priorities be over the next two or three years?

One is certainly coming out of the pandemic and helping the CDC and other federal partner organizations. Working a lot with the CDC on establishing the public health infrastructure of the future and how we think about that as more of a public health ecosystem. Thinking about EHR systems as being sources of information, with a variety of other sources of information, that can be brought together on demand in a more dynamic internet sort of way to be able to respond to crises as part of an ecosystem rather than being siloed systems. That’s a lot of work.

There’s a lot of investment into these systems going on right now because of the pandemic, working hard to say, how can those address the current need as well as the investments toward what the future needs are going to be? We have under-invested in public health infrastructure for too long, which is partly why we are where we are, so that will certainly be a focus area.

Now that the applicability date for information blocking has passed, working with industry to iron out the wrinkles. Compliance is obviously hugely important and there are penalties and real rules, but I really want and hope and expect that we are going to be able to move beyond that to say, I’m not doing it because I have to do it — which means that people will meet the letter of it and perhaps not go further — but I’m doing it because there’s an opportunity here, a new paradigm for the way we think about healthcare. There’s a new paradigm for the way we think about engaging patients. There’s a new paradigm for the opportunities that sharing information presents back to me. Yes, I have to make more information available, but that also means that other organizations have to make more information available to me. I have the opportunity to be able to demand that more of that information be made available to me than I did in the past, and I should be thinking about that.

There are a lot of wrinkles that we have to iron out for sure. We are trying to do that with FAQs, and with something as complicated as healthcare, you put out a regulation and a million questions start coming, all of them legitimate. There’s that twist on it, and, oh, here’s a circumstance that we didn’t think thoroughly about and now we have to give an interpretation of that. There’s certainly a whole bunch of that that we need to get past, and that’s all understandable. But I want to be able to help the industry get to that next level as quickly as possible.

We are paying a lot of attention to structured data right now, which is the USCDI, the United States Core Data for Interoperability, and those elements that are required to be made available for the first 18 months through APIs. But we should also not lose sight of where the puck is headed here, and that is toward that more general construct of EHI, which is electronic health information. That is the electronic representation of the designated record set, which is in theory — I’m putting air quotes around this – “all of the patient’s data.”

We know that all is a very slippery term because there’s a lot of information contained in a hospital system, especially for a complex patient. Defining “all” could be very tricky and may not be what someone wants. But going back to the earlier part of our conversation when we were talking about algorithms, when you start to think about all of that information being made available now, it’s the information beyond what is structured. The idea is that we shouldn’t be waiting for data to be standardized and structured before we say that it should be generally available, in part because if that is rate-limiting, it’s going to take us a long time to get there.

The standards work slowly and methodically. That is saying that that information just needs to be made available in whatever form it exists, then let the users figure out what they’re going to do with it. But the obligation to make it available is preeminent. That speaks to algorithms and what we’re going to be able to do with that data. Who is going to be ahead in making sense of that data once it’s available and being able to do high-value things with that information?

I’ve been trying to talk to as many people as I can about  remembering that is coming. How are you going to position yourself for that? What are the tools that you are going to bring to bear? How do we start to develop those tools and those capabilities to be able to take advantage of that?

Equity is a huge priority. Thinking about that from a design perspective, meaning all the way down at the core, so that disparities are not an afterthought or a hope for output of the system, but something that is baked more into the fundamentals of the way data is collected and the way data is aggregated and analyzed. Some of that relates to the bias questions that we were talking about before, and ultimately, what actions we want that information to be able to inform. Because there’s no data collection for the sake of data collection — data collection has got to be geared toward a specific set of decisions that you’re going to make and a specific set of actions that you want to take one way or the other. We haven’t had enough of that. We need to think about health equity and the data that we want to be able to get to help inform health equity.

The last thing is interoperability as it relates to networks. TEFCA — the Trusted Exchange Framework and Common Agreement — is a really important part of thinking about that as we enable these networks to finally be able to rationalize interoperability across the network, so that as a user, that is all deprecated into the background. When I’m on my AT&T phone, I don’t think for one second about how it magically connects me to a Verizon user or an Orange user in Europe. But right now, unfortunately, providers do have to think about that. I’m hoping that we can get TEFCA to a place where it pushes all of that to the background so that we no longer need to think about that, and we have interoperability for users that just happens in the background and no one needs to worry about the engineering piece on the front end.

HIStalk Interviews Micky Tripathi, National Coordinator for Health IT (Part 1)

Micky Tripathi, PhD, MPP is National Coordinator for Health Information Technology.

What has surprised you most about working for the federal government?

The extraordinary amount of work that it takes to align the federal partners, working within the federal government. I don’t think I appreciated that as much when I was on the outside, where all my interactions with ONC were with things that were externally facing. I always knew that there was a role that ONC plays in coordination of the federal partner activities, but now that I’m on the inside, I appreciate how much there is, how hard it is, and how much opportunity there is. 

More and more of them are discovering that they can do things with electronic health records. As we start to move to an ecosystem that has FHIR-based APIs, they’re starting to see the value in that, which is both a blessing and a curse. The good news is that they are seeing it, and the bad news is that they are seeing it, because keeping all of that aligned is a growing challenge.

Within HHS alone, CMS creates and consumes a lot of data, FDA is looking at real-world evidence and post-marketing surveillance, and CDC has data-driven public health activities. Is there a big table where all of HHS’s groups figure out an overall HHS data strategy?

ONC chairs the Federal Health IT Coordinating Council, which brings together all the federal partners who have health IT activities going on. The last time I looked, that was probably 30 to 40 federal agencies across the government participating. I’m trying to energize that so that it has focus on particular topic areas where we can make forward movement. That’s a place we can exercise a little bit more to get more coordination.

Some of it is just reaching out and having bilateral conversations, figuring out where there’s a connection of dots to say, wait a minute, I just heard the same thing from four different agencies. Let’s try to get them together and start to think about how we’re going to think about this together.

ONC’s initial work with Meaningful Use was focused on increasing EHR adoption, and now as a by-product, we have real-time data available to support pandemic-driven clinical, operational, and research needs. Are we just starting to realize how much information we have immediately available?

I think that’s right. We had high level, gauzy ideas about the learning healthcare system. I’m not saying that to deprecate it. You would be able to tap into different types of data in more of an ecosystem kind of approach. We never really operationalized that, or we were never really forced to operationalize that. Part of it was probably because until very recently, like the last couple of years, we were were focused on laying the foundation, with that always being a part of the goal. But now here we are with a pressing and urgent need that has really tested the system.

As we look ahead, and as you pointed out with FDA and others thinking about real-world evidence and other kinds of opportunities, that is starting to come into play. It is now more more specific. That said, we are just at the beginning of thinking about how to do that. If you look at the pandemic, for example, we made very little use of the EHR systems that are in place. We hadn’t built the ecosystem around it to tap into that information in ways that are more functional than one-way reporting for what public health needs to be able to do in a pandemic. That’s the next chapter.

We’ve seen pandemic-related technology failures, such as rarely-used contact tracing apps, failed vaccine management and scheduling systems, and reliance on paper cards to prove vaccination status. How does HHS look at the role of consumer technologies as part of public health?

In all of those areas, there is a lot of opportunity for a lot of potential, and potential and opportunity with the maturity of that kind of ecosystem. Part of the challenge, probably with all of the examples that you raised, is that if you are going to think about those from a consumer access perspective — and a couple of them arguably could be thought about that way, like contact tracing and the vaccination credentials, with scheduling being a little bit harder – you would want to leverage the maturity of patient experience. Patients are familiar with the idea that there are use cases where they have, at their fingertips, control of health data. They can interact, both in terms of getting data as well as interaction bi-directionally or in a more synchronous way than they are able to today.

We are at the very beginning of the beginning. Most people don’t realize that they can download records onto their phone, for example. Because of the way that health information technology has rolled out over the years, and because it’s new in terms of EHR penetration, for whatever reason patients don’t naturally think of apps as being the way that they can interact with healthcare, even though they do that in every other walk of life, such as Uber or ordering food or whatever, where they turn to their favorite apps. Until now, that has been an unnatural act for them. I think that will be more of a natural thing in the next few years and we’ll probably get a better reception for these kinds of capabilities.

We will also face a challenge in that we want to make the opportunity available to patients, but we still don’t have the answer of how many patients actually want to have that kind of interaction with healthcare. To me, that’s an open question. I don’t think that that undercuts at all the obligation on us as an industry to make all of that data available in the easiest possible ways possible for individuals so that they can take that opportunity where they want it. But I do think it’s still an open question of how much they patients themselves want to be in the driver’s seat for that.

We haven’t seen much evidence that supposedly empowered healthcare consumers will vote with their feet in leaving providers who don’t practice transparency or interoperability. That means the only available recourse is for a patient to recognize then their provider isn’t following the rules, then take the trouble to report them for possible government action.

There are real questions about whether healthcare will be a consumer good that conforms more to neoclassical economics and markets than not. That is a testable hypothesis that we will see. But I agree that there could be challenges there in terms of consumers wanting or being able to act in that way, because of the complex economics of healthcare and the complex ways in which people decide on their care. And how willing or able they are to break out of that to do consumer search, and thinking about healthcare as something that you do real search for based on value, cost, and quality in the same way that you do with other kinds of goods and services.

My kids certainly approach healthcare differently. They are much more willing to go out get healthcare on the spot market, as it were. Whereas when I think of my own care, I’m in a system and I’m going to stay in that system because I’m concerned about interoperability not happening. I’m voting with my feet to say, I’m going to go to a place where I know that all of my records will be in the same place. It’s multi-specialty and all the specialists are are tightly connected to a hospital in a very good hospital system. I’ve basically voted with my feet to say that I want to make sure that I’m in a system in which I know that interoperability is going to happen.

Whereas my kids are much more willing to just be in the spot market and say, I’ll just find a doctor based on some kind of scheduling app or whatever it is. I’ll go see them, and then I’ll go somewhere else. Now of course they have few needs and lightweight needs, and maybe their views will change once they get older and they have more acute needs or more ongoing needs. But we should all leave open the possibility that we’ve got a generation of digital natives who may genuinely think about this differently.

The providers in that spot market that you mentioned are likely to be in urgent care or telehealth companies that probably need the patient information that big health systems have, who in turn aren’t as interested in getting data from those spot market providers. How do you address information blocking if it is mostly big health systems that aren’t willing to share?

That’s all a part of information blocking. There is a requirement for them to share that as the first instinct, and to only have good reasons for not sharing. It is precisely designed to address that.

Going back to that expectation of a younger generation, although we don’t want to paint people with too-broad strokes, there is an expectation that interoperability is happening in the background. My kids, even if they are on those spot markets, have an expectation that their information is being shared behind the scenes, and may they have less tolerance for that information not being there. Then, through their own searches, they may discover places where that’s happening versus not happening because of efforts that are going on or not going on behind the scenes to get that information to the right place. There is certainly a regulatory angle to that, which is about information blocking, but there could be a consumer demand angle for that as well.

How do you educate consumers who perhaps have never actually seen interoperability in action that they should have those expectations and that providers who don’t share information are not complying with federal requirements?

Interoperability is happening that is invisible to patients. They expect that more of it is happening, by and large, than is actually happening, which is always eye-opening to some people. Their ability to have apps with features they are used to in other parts of their lives might be a way of being able to expose in a more direct way whether interoperability is happening.

Some of the more innovative payer systems do these kinds of things, with apps and functionality where users can track the progress of prior authorization and referral notes. Those can start to put in front of the consumer the basic kinds of customer service things that they see happen when they go to Home Depot and Amazon, but that they don’t see happen in healthcare. That can make it a more explicit what’s happening behind the scenes and can point out where some of those things aren’t happening behind the scenes. I don’t think that happens overnight and that’s fairly spotty what I just described, but it’s not hard to imagine that if you start opening that up, that starts to give more visibility and more of a window into what’s going on behind the scenes. But right now it’s all been under the covers.

Who do you expect to file information blocking complaints, consumers or other providers?

We are open to all, obviously. I find it hard to believe that a large number of patients would be coming forward with those kinds of complaints about provider-to-provider exchange, simply because they may not be aware of it. You can imagine more coming forward with complaints about their own access to their own records, which is also an important part of information blocking. The more savvy have an expectation of getting access to their own records. I can imagine more of them filing a complaint about information blocking because their records should have been transferred from the ED to their primary care physician and weren’t.

That seems like a less likely scenario to me, but again, that could change. We’ll see what happens. Because of institutional knowledge and the awareness in the industry, more of the complaints are going to come from organizations, whether it’s vendors, providers, networks, or those who are covered by them or who have an expectation of what the opportunities might be with information blocking, and then try to test it and find that it’s not there the way they perceive it should be there. I think that’s going to be more of what we see, but we’re still very early.

HIStalk Interviews Charlie Harp, CEO, Clinical Architecture

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

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

HIStalk Interviews Andrew Smith, President, Impact Advisors

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

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

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

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

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

Are consumer-facing technologies getting executive and budgetary attention?

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

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

Who drives that process in health systems?

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

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

HIStalk Interviews Rob Culbert, CEO, Culbert Healthcare Solutions

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

Tell me about yourself and the company.

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

How has the pandemic affected your business?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

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

HIStalk Interviews Josh Schoeller, CEO, LexisNexis Healthcare

Josh Schoeller is CEO of LexisNexis Healthcare.

Tell me about yourself and the company.

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

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

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

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

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

To what extent are health systems using outside data?

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

What are the challenges and imperatives around provider data management?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

How will vaccination passports work?

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

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

How has the pandemic changed the company’s business?

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

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

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

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

Do you have any final thoughts?

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

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

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

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

Tell me about yourself and the health system.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

HIStalk Interviews Ann Barnes, CEO, Intelligent Medical Objects

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

Tell me about yourself the company.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

How are health systems using value sets?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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