HIStalk Interviews Suresh Venkatachari, CEO, Healthcare Triangle, Inc.

Suresh Venkatachari is chairman and CEO of Healthcare Triangle, Inc. of Pleasanton, CA.

Tell me about yourself and the company.

Healthcare Triangle combines two great companies, each successful but stronger together. One is rooted in proven healthcare and business methodologies, and the other is a born-in-the-cloud early adopter turn global leader. Together, we are a 360-degree solution with the know-how and innovation capacity to meet technology, data, care delivery, and business operation needs.

We offer solutions to three core healthcare customers — hospitals and health systems, health insurers, and life sciences companies. I’m proud of our commitment to support each one’s respective effort to improve health outcomes by enabling the adoption and optimal use of new technologies, data enlightenment, business agility, and response to immediate and emerging business needs and market trends.

I have 30-plus years of experience in creating and managing businesses in cloud, ecommerce, IT solutions and consulting services in healthcare, life sciences and banking. But nothing compares to the excitement of today’s healthcare innovative landscape.

How does the combination of traditional health IT consulting, such as EHR implementation and optimization, and cloud transformation and security benefit clients?

I am incredibly excited by this combination and its advantages. Our traditional consulting background helps us understand the complex challenges that are facing healthcare CIOs in the current ecosystem. Our technology expertise in cloud transformation and security in the life sciences space means we understand the power of cloud transformation in highly regulated environments.

The combination also guides our clients on a practical and achievable roadmap of digital transformation. For one hospital, for example, our work focus might be disaster recovery and backup, while simultaneously leading higher-level discussions on end-to-end managed healthcare IT services with the C-suite executives. Simply stated, we are all about alleviating a lot of headaches for the CIO with solutions for operational efficiencies and lowered costs.

What’s really thrilling is that bigger picture, the healthcare industry is on the cutting edge of realizing a monumental pivot among healthcare providers and life sciences. Significant high-tech advancements are happening in personalized healthcare at every stage of the patient’s healthcare journey. Innovative and customized solutions are reshaping delivery of better access to smarter and more effective care to everyone.

What pandemic-driven technology challenges and opportunities will health systems see in the near future?

We’ve recently highlighted key challenges with technology extensively in our “Return to Revenue” series. But underlying that, the greatest challenge will be maintaining the business agility that is needed to react quickly and deploy those technologies that have an impact on patient safety and are demanded by the patients themselves.

Our clients succeeded in meeting the COVID-19 crisis head on by rapidly adopting and adapting telehealth technology. Next, we recommend that they go to the next level by deploying virtual waiting rooms and exam rooms, in-home monitoring, and data solutions. Traditionally, these types of projects take years to plan and implement, but we’re seeing increasing need to drive change in weeks and even months. HTI is their enabler to continue to iterate quickly and set a roadmap for continuous practical innovation.

On the life sciences side, we witnessed two immediate COVID-19 related challenges. First, the need to analyze data extremely rapidly. Second, the need for rapid deployment of digital health technologies.

We have a customer, Stay Smart Care, who is the perfect example of digital health excellence. Their business purpose is to help people safely age in place in their home. Stay Smart Care offers remote patient monitoring, with real-time sensor data, dashboards, and chat functions. We built the entire digital health platform, from the digital health management application to the secure, compliant patient communication application. This technology offers amazing potential in multiple areas of telehealth.

My team has a deep knowledge of the healthcare system, cloud technology, and digital health applications,. We are advising our clients about solutions that will help them navigate and succeed in the next normal of telehealth.

How have the data sourcing and analytics needs of life sciences companies and researchers changed as they address COVID-19?

COVID-19 has dramatically fast-tracked research toward treatment and prevention. New collaborations are springing up to protect public health. Not surprisingly, researchers and life sciences companies find themselves having to obtain, analyze, and share a high volume of test results and other data rapidly and safely. The solutions we offer for cloud transformation make management and analysis of that data less challenging and allow researchers and life sciences companies to focus on what counts most, which is saving lives.

Specifically, our DataEZ solution – a data lake as a service, if you will – is used by five of the largest global pharma firms. It allows rapid analysis of clinical trial information, for example. One client went from conducting clinical trial to submitting the reports to compliance agencies in a matter of weeks. Before this, the process required several months.

Health system IT departments have quickly rolled out new technologies such as telehealth, chatbots, and remote worker support, delivering quick wins rather than the more typical implementation projects that can take years. Will this experience change how those IT departments manage projects and technology going forward? 

We did see some very quick technology implementations over the last few months. I hear health system leaders talking positively about the quick consensus-building and lean approach to implementation that it took to make that happen. It is a very agile approach to deploy a solution and iterate on improving it over time based on real-life experience impacting productivity and costs. We focus on delivering business agility whether we are supporting a cloud migration, providing data insights, or optimizing an EHR workflow, and I hope that momentum is sustained going forward.

How will cloud-based services change the job of the health system CIO over the next five years?

We’ve been saying for years that the role of the CIO is changing from functional technology leader to business strategist and transformationalist. Trends in innovation driving that change are digital health, personalized healthcare, telehealth, remote monitoring, data-driven decision support systems, and blockchain innovation. Cloud is the key that unlocks the capacity in our client CIOs.

Taking advantage of cloud technology and automation means that CIOs can focus on full-scale organizational transformation and drive business agility into their technology platforms. Instead of 30-day cycle to spin up a server, we’re talking seconds on the cloud. And that’s a cascading effect, right? Every win along the journey to the cloud allows the organization to transform faster and faster in today’s changing environment and our client CIOs to drive that change rather than constantly react to it.

What are your medium-term goals for the company?

We want to drive the conversation centered around digital transformation into a new phase of bold action. The disruption to the industry and our communities demands that we use technology to strengthen our ability to deliver healthcare despite the impact of external forces. We are flexible and practical. We will meet clients wherever they are in their digital transformation and make great advancements together accelerating the value that they see from technology.

The drive to improve care delivery and business agility in healthcare is limitless. I know that we are ready as an industry to deploy new technologies, gain enlightenment through data insights, and push toward the next frontier of digital innovation. That’s what Healthcare Triangle is here to do — to reinforce healthcare progress.

HIStalk Interviews Gadi Lachman, CEO, TriNetX

Gadi Lachman, LLB, MBA is president and CEO of TriNetX of Cambridge, MA.

What was your reaction when you heard that prominent medical journals retracted two COVID-19 research articles due to concerns about the quality of the underlying aggregated EHR data that researchers analyzed?

It’s easier for me to talk about what we do and how we do it as opposed to talking about other companies. I’ve never heard of Surgisphere, the organization whose data was used.

EHR data is super valuable. In the world of clinical research, you want to use all the tools available to develop therapies, to develop cures, and to save human lives on a massive scale. That goes without saying. There is a powerful do-good in this industry of utilizing data for drug development, for therapy development, to fight disease, and to find cures.

Then, what is data? There are many different categories of data. Claims data, EHR data, data collected in the lab in the process of a clinical trial, patient-reported outcomes, and things like that. EHR data is forever being used in the clinical research realm. Every data type has its pros and cons, and every data type has a lot of value in helping those who develop new cures and new therapies.

I would almost say when you’re developing a new cure or you’re trying to understand a disease, you cannot do that without looking at EHR data, because that tells you what happens in the inpatient and outpatient settings. What happens with those patients? What therapies, what diagnoses, what medications, what do they report as going on with them, and what is the medical community doing to them? Then you follow to see the outcomes of those interventions.

EHR data is fundamentally basic for clinical research and has been widely and popularly used in that space. The question becomes, how can you ensure the quality? How do you know, as a researcher, what data you are looking at and what processes have been put into place and how much capital and human labor has been deployed to ensure the quality of the data?

TriNetX is a global network. We are in 26 countries. We take data for more than 150 healthcare organizations, including the likes of Johns Hopkins, Boston Children’s Hospital, MUSC, University of Iowa, and others. We work with many, many pharmaceutical companies, such as Sanofi, Novartis, AstraZeneca. We interact as a trusted advisor with those healthcare institutions. We are making sure that this EHR data can be used for clinical research. We look at it, we test it, and we compare it to other big data that we have to make sure it’s consistent. We look at how people are coding and inputting the data and report back any inconsistencies. We compare structured data to unstructured NLP data and see if there are discrepancies.

We have deployed $150 million of capital to accomplish that. We have people all over the world. We have data scientists who make sure that the data is clean and consistent. That data is getting a lot of love and attention. It gets to a level of quality where a researcher can say, I trust it. It makes sense to me. I’m going to research on it. I’m going to publish on it. It takes a lot to get to a level of quality that will be acceptable by the industry, by the standards of clinical researchers, and valuable for humankind to drive what we need to drive.

When I read about the processes or the numbers of things that have been published, those numbers didn’t make sense to me. It takes more than a very small group of people to do what needs to be done to get to that level of quality that is required.

In normal times of publishing and research, there is time to do things. We spend an ungodly amount of time on the data quality, but then there is time for the researchers to run it by peers. COVID-19 was almost the perfect storm for this bad episode, where everyone was running so fast that there was no time for researchers to perhaps do the checks and balances and the validation that they would otherwise do. A lot of people with good intentions. Researchers and physicians spend their career to save lives. They were caught in the middle of that perfect storm and they maybe failed. They didn’t have enough time to do what they need to do to check the quality and validate. It was just happening too fast, and this is where mistakes can happen.

Even within a single institution, researchers are sometimes pressing for data that doesn’t exist in the black-and-white form they expect, with consistent validation and procedure across service locations and across EHRs that fits neatly into a table without requiring a lot of analyst footnotes. How do you turn data from multiple health systems into a reliable source for research?

No two installations of the same EHR will ever be alike. Then you compound the problem by looking at different EHRs, then compound it again by looking at different countries.

We have invested a lot of hours and capital in the past six-plus years to tackle exactly that problem that you said. We have almost a Rosetta Stone in our master ontology. We have a centerpiece, a language that TriNetX adheres to. You take the best standards from all over the world and then go healthcare organization by healthcare organization. It doesn’t matter what you find there — you have to map it into your master ontology.

But this is the beauty of it. By mapping it, you develop a deep understanding of how that healthcare organization is talking, because that’s the only way to map it to something that is more coherent and consistent. That is what we do. It’s difficult, but by doing that, you start to create this standardization abstract layers. The analytics that we build, and all the functions that need to interact with the data, can now speak one language because we’re taking care of the translation. It is a massive investment. It is a core component of what we do.

I’ll give you an example. When COVID-19 happened, old diagnoses for old coronavirus conditions existed in the platform. Very quickly the different regulatory organizations started to release new codes to capture those patients, specifically the COVID-19 patients and tests. We implemented those codes immediately. But that doesn’t mean anything because your hospitals have to report on that as well. We work with an amazing network of healthcare organizations that rose to the challenge in starting to report on those codes.

It’s an informatics and software effort on our part, but it’s also a coding and informatics effort on the healthcare organization’s part. You apply all the quality checks and all the work that we do together as a network to be able to then show researchers and government entities that we’re working the results. These are the patients that we see. This is what they have. These are their profiles. Let’s see what’s working, what’s not working. The utilization of drugs, the utilization of everything. Outcomes. This is the result of massive informatics efforts where all the players have to join forces. It worked very well, it worked fast, and it was on a global scale. Not just the US, but hospitals all over the world rose to that challenge.

What questions should researchers ask to make sure the data that someone else collected is appropriate for their study?

You have to work with reputable companies. We announce the names of who joins our network. We openly talk about the quality processes and the checks that we do. We have hundreds of publications that have been reported on our data. It creates a level of trust. A network of more than 40 industry partners — healthcare organizations, life sciences, and and research entities — have been using us for the past six years and have trust.

A researcher will very rarely go to the record level. No one will let them see that anyway. Even if you looked at the record, do you also want to interview the patient? When you interview the patient, do they even know what they have? At the end of the day, you must trust an organization to create a quality data asset for you. You can audit it if you want. We are very open for everyone looking and auditing our processes, how we look at data, how we do our work. There is a lot around data governance, process, and people that we are very open about. We are open to suggestions and always getting better and better. That creates confidence within the research community to use the data assets that we have time after time.

A lot of research has been published in the last many, many years. A lot of the time, we allow researchers to analyze our data to verify that they can replicate the results that have been achieved through other means. By doing that, you create the ability to validate that a similar set of data on which you run a different set of science and algorithms on it gives a similar conclusion. Or you get a different conclusion, but you can explain the difference. That validates that you can trust this data asset, because time after time, it delivers the answers that you expected, which then gives you confidence to start asking new questions.

Are you seeing impactful COVID-19 research being performed using your platform?

It’s a huge impact. The pharmaceutical industry, contract research organizations, government, and we ourselves are publishing around COVID using our data asset. We are helping find a lot of things that are moving the industry forward in this rapid development of cures. For example, we have published that with COVID, compared to other like conditions, you get more strokes with younger populations. We have validated that assumption. It’s a huge learning, because physicians and the frontline people who are treating those patient now know that in young patients, they need to be on the lookout for other things that could be going on and make appropriate diagnosis and therapy decisions. It saves lives on order of magnitude immediately, not to mention providing insight for those who develop the therapies.

We have many examples of uses of drugs and outcomes that we supported. TriNetX has been in the forefront of fighting the COVID-19 pandemic. That makes everybody who works at TriNetX proud.

HIStalk Interviews Philip Meer, CEO, PatientKeeper

Philip Meer, MBA is CEO of PatientKeeper of Waltham, MA.

Tell me about yourself and the company.

I grew up in New Jersey. I’ve spent my entire career leveraging software to advance a greater good. I’m an operator by trade. I enjoy solving problems and tinkering, using operations and using software to ultimately improve the quality of human life, but more tactically, to help companies scale their operations and make things better, faster, and cheaper, ultimately benefiting the end customer.

PatientKeeper is a 20-year-old software company whose mission is advancing healthcare by creating instinctive, empowering technology that respects the importance of the physician. I joined PatientKeeper because we can solve the big healthcare problem of providing a better clinical experience for the physician, who is at the core of what we do.

As an operator and tinkerer, it must be either terrifying or exhilarating to see healthcare and technology throwing out the rules and trying new ideas in response to the pandemic.

I think you said it very well — terrifying and exhilarating. What’s terrifying to me about the pandemic is that the healthcare IT and software community has not fully grasped the size, scale, and scope of the pandemic. It’s just now, a couple of months in, that we are advancing real solutions to support the healthcare ecosystem. It is terrifying because it took us by surprise. I’m not sure what we could have done differently, but it is terrifying to see the scale of a pandemic and what it can do to our healthcare system.

What’s exhilarating is that healthcare was already undertaking new strategies. Telehealth and home care allow mobility and enable the provider to provide care wherever they are, under whatever circumstances come their way. I’m proud as an operator that we are deploying software in these areas that the healthcare community had begun to embrace pre-COVID and now have accelerated with the pandemic.

What have we learned from moving physicians out of their specialties, and in some cases out of retirement, and placing them on the COVID front lines in new hospitals that have unfamiliar technologies and workflows?

The primary learning is that the new norm is mobility — the ability for a provider to render care, collaborate with the care team, and to reach patients and family members in an ergonomic way. Collaboration, both inside and outside the four walls of the hospital, must be a strategy when it comes to healthcare technology.

EHRs are great systems of record, as they were designed to be. But we have learned that the imperative is a system of experience, in which a clinician can provide care and also ergonomically tackle their administrative and data entry responsibilities in a way that minimizes their burden. Mobility and ergonomic systems that support physician productivity are no longer nice to have — they must be at the forefront of healthcare as we look beyond the pandemic.

How will increased use of telehealth and remote monitoring and the resulting changes in clinical collaboration change the demand for technology?

There’s a growing need to have, at your fingertips, a workflow tool or a system of experience where you can do your job in a way that doesn’t sacrifice the interpersonal care that is needed. That is the jigsaw puzzle that we are all being asked to solve right now as software engineers and technologists. That is the puzzle that PatientKeeper is being faced with.

How do you do clinical documentation without sitting at a dumb terminal by a patient’s bedside? How do you capture the work you’re doing from a billing perspective by quickly speaking or typing into your mobile device from the golf course or working from home? How do you view lab results, x-rays, and lab results virtually and be able to take actions to support your patient? No question about it, the ability to deliver care in a virtual setting and tools that provide an ergonomic experience for the physician have become the imperative in the COVID world and beyond.

What should the working relationship be between EHR vendors and companies like yours whose products improve and in some cases replace theirs?

Surveys have found that more than 50% of healthcare executives wish they could have made a different decision in their EHR selection process. I don’t fault the EHR for that. It was designed to be a system of record, and over the last 20 years, EHRs have done their best to serve the healthcare community in that way. PatientKeeper’s 20-year experience has been focused exclusively on the actual experience that the physician undergoes to do their job and to render care to the patient.

It is a complementary relationship between EHR vendors and PatientKeeper and other third-party tools that focus on end user experience, workflow, mobility, and integration that fits the way the provider chooses to practice medicine. The key for PatientKeeper and others going forward is interoperability. How do we work with multiple EHRs in a standardized way so that clinicians can serve patients seamlessly regardless of the underlying tech stack and EHR that they or their employer have chosen?

How is that vendor relationship managed, in terms of both technology and philosophy?

I don’t think there’s a simple answer to that question. From a technology perspective, I don’t know of any major EHR vendor who is against interoperability. Judy Faulkner herself recently said that Epic invented interoperability or created the concept of interoperability. From a technology perspective or philosophical perspective, the closed, monolithic EHR system will not survive into the next decade. It is inevitable that with standardization, open architecture, and APIs that EHRs will have the ability to provide a common patient experience across multiple EHRs.

From a philosophical and competitive perspective, the companies that succeed will be those that put the physician experience first and spend time speaking them and understanding their experience. The product in healthcare is the ability to render care in the best possible manner and to incorporate the best possible physician experience while serving interoperably among multiple EHRs or any healthcare tech stack. That has been our mission at PatientKeeper and will continue to be our mission in the coming years.

How is it different working under the ownership of hospital operator HCA instead of as a standalone vendor?

It’s all positive as I see it. One of the reasons I joined PatientKeeper was the support and the partnership between PatientKeeper and our owner. HCA offers us a treasure trove of physicians to observe, to listen to, and to help design PatientKeeper solutions. That’s the single biggest advantage of being owned by HCA.

Secondly, HCA does not just focus on one thing. They are across 185 hospitals and 40,000 clinicians across all service lines, practicing in many of the geographies around the country. We can truly understand the breadth of a solution that we need to provide, but we can also capture the depth of the solution required for a particular service line or geography. HCA is the greatest learning lab any CEO could ask for.

Financially speaking, HCA is an investor in PatientKeeper, but we also serve a large bulk of commercial customers beyond HCA . We listen them to and incorporate best practices across HCA and non-HCA systems. That gives PatientKeeper a huge competitive advantage in understanding what the end user, the clinician, is looking for so that we can deliver world-class solutions to meet those needs.

What will be the most significant impact of COVID-19 on the company?

Mobility and mobile solutions have always been part of our strategy and a differentiator for us. The greatest impact is that we will emphasize mobility even more in our strategy. The ability to provide clinicians with mobile tools on their smartphones and IPads so they can do their job virtually with a better clinical experience will have the biggest impact on PatientKeeper. We will accelerate our investments in mobility and mobile capabilities. It will also accelerate our partner strategy, where we will be looking to do more on the telehealth and home healthcare side with third parties that are working diligently and quickly to provide solutions based on the new way that healthcare is being practiced as a result of the pandemic.

Do you have any final thoughts?

We have done a good job of innovating in healthcare since 2010. The healthcare ecosystem has better solutions that allow providers to deliver better care for consumers and patients, with a better experience for the providers themselves. We haven’t done enough. The next 10 years will be defined by the patient experience and the physician experience, and I’m so excited by that. That creates a great opportunity for an operator and a tinkerer like me to get involved and actually solve a greater problem to meet the healthcare community’s needs in 2020 and beyond. I am excited by the opportunity to take on this challenge and to lead PatientKeeper.

HIStalk Interviews Richard Atkin, CEO, Greenway Health

Richard Atkin, MBA is CEO of Greenway Health of Tampa, FL.

Tell me about yourself and the company.

Greenway Health’s customers are predominantly physician-owned practices, Federally Qualified Health Centers, and community health centers. We offer a broad range of solutions to those customers. 

I’m an engineer by education and training, so I tend to think about problem, process, root cause, and solution. I’ve been fortunate enough to have been in healthcare for over 25 years in a number of roles, a number of them at the CEO level, with companies such as Sunquest Information Systems, Spacelabs Medical, and Datex-Ohmeda, which is a part of GE Healthcare. Most of those are in the acute care space, so the transition to Greenway and ambulatory care has been a pretty exciting journey for me.

What technologies have seen uptake during the pandemic that will remain in the mainstream afterward?

Certainly the pandemic has validated the role of the electronic health record and the importance of the data that’s within it. I think it will also create an interesting dialogue between what is personal about the data and what can or should be shared for the benefit of the greater good. That’s one aspect that will become increasingly discussed going forward.

You mentioned telehealth. As restrictions ease and there’s a return — not to normal, but to a new normal — technologies for remote consults and ensuring that those consults are seamlessly included in the patient record will become increasingly important. The pandemic has created an awareness that you don’t always need to be face to face to get the advice and the treatment that’s required.

The importance of patient engagement solutions such as portals and messaging will, along with the telehealth, become increasingly important. The connected patient and the use of the internet to that ensure information flows seamlessly. All of those are going to be more important. It probably put more context to the new regulations, like 21st Century Cures, which were aimed at making data more liquid and transportable. It’s going to be an exciting time.

The other thing that was occurring but will be accelerated is the view that fully cloud-native solutions —  SaaS, cloud solutions, hosted solutions — create added benefit. They maybe reduce the reliance — certainly in practices, which are relatively small companies or organizations, small businesses — on in-person back office support through the increased use of SaaS solutions.

Are you seeing new demand for public health reporting from EHRs?

Public health and population health are always being discussed. The adoption has been lower than previously anticipated. A large proportion of our customers, the Federally Qualified Health Centers and community health centers, operate in that public health space.

Most of the discussion about data or information has been that it’s personal and private, and therefore is owned by the patient. Of course, that’s still true at a very large level. But for the public good — for public health, social determinants of health, and the management of things like a pandemic – there is a need to be able to share information, which currently could be difficult with the focus that has been on PHI as the primary driver of the conversation around data and information.

Do you see more emphasis on specific patient privacy concerns related to EHRs?

That has always been a significant part of the ambulatory space. Protected health information and the privacy associated with that has been restrictive in terms of how we use data. I understand the concern about selling information or having a commercial relationship around the data. I was really referring to public health and pandemic data analysis and management, even to the extent as we come out of the COVID-19 pandemic, the way in which we could use data to ensure that the ambulatory practices get the support that they need.

Greenway serves largely physician-owned practices or independent practices and businesses. Headlines around the pandemic are largely about the acute care space, and rightly so since they are on the front line, with bed shortages and the impacts on staff. Those are real challenges.

For the ambulatory segment, the issues are significant in the physician office space. Around 97% are reporting a reduction in revenues. There’s about a 60% or 70% reduction in visits, a 75% to 80% reduction in revenues, affecting over 97% of those practices. Those are huge issues. Many of them have had to furlough, lay off staff, or even close the doors, particularly those that serve the more elective elements of ambulatory care. 

Restarting those businesses is going to be challenging. We could use analysis of data to help, whether at the state, local, or even the national level. Some of the data that is currently blocked by PHI could help signal when and where practices need help. That’s a very different use of data than selling it to a pharmaceutical company or trying to monetize it. We need to get our arms around public health and public good as we think forward beyond the pandemic.

Are those independent practices at risk of closing or being acquired by health systems that have deeper pockets?

Those are real risks. Maybe for context I can describe how we’ve been dealing with that during the emergency, because many of our customers are operating at very reduced levels of visits. We pulled together a team early, led by our chief medical officer, Dr. Nayyar. The regulations are changing rapidly, being alleviated. Telehealth is one example, but there are many others, including billing requirements. Our team is reviewing, multiple times a day, any changes in the information at the state or the national level. We have ensured that the EHR solutions have the right workflows within them — diagnosis codes, CPT codes, billing codes, et cetera. Then we’ve put together a series of educational webinars, largely around the business aspects of running a small business or small practice. What grants are available, small business loans, how to apply for the loans, some of the criteria.

We are focused, at the moment, on helping them get through in the best way they can. Our view is that if we do that, first, that’s our responsibility as a partner. Second, if they come through this in the best shape possible, then we can work with them beyond this pandemic into the new normal.

There are reports that many physician-owned businesses might look to the local hospital to acquire them. Of course, those hospitals themselves are being significantly impacted, so that may or may not be the real path, or maybe it’s a private investment.

Ambulatory care is where we all, as a population, interact most with the healthcare system. We rely on the acute care space when we really need it. But on a day-to-day basis – for preventative medicine, routine visits, even medical exams for schools and sports as they restart, and so on — it’s the ambulatory part of the healthcare system. My view is that while it will be affected like every other part of society and the economic system, it will survive. It’s a much-needed part of the healthcare system, and it’s just that their needs will be a little different. Part of the solution to that is the technologies that we just talked about.

The pandemic took patient portals from an “only in healthcare” disdain to becoming a central point of presence that providers are using to launch new patient-facing technologies, such as chatbots and telehealth visits. How are patient portals being viewed now?

I agree with you. The patient portal is a critical and essential part of the suite of solutions. It always has been talked about that way, as you imply in the question, and yet the full adoption and then the full utilization of the portal has been relatively low.

Like telehealth, I think this will be one of those catalysts to say that the best way to interact with the patient — to keep the conversation going between the physician and the patient, particularly in the ambulatory space — is via a portal. There’s much more that you can do with it than pay your bill.

We are seeing the patient portal as a key part of our strategy. We included it in our product strategy under the heading of healthy outcomes. That’s where the patient-centric solutions are, along with some other ones like the population health and public health that we talked about. The role of ambulatory care is just as much to ensure that the population is healthy and doing the proactive things to stay healthy as it is to treat the illnesses that people have.

How would you characterize the state of interoperability?

It is still embryonic at best, let’s say. I don’t think the technologies, or the history of technology, have helped greatly, since healthcare was pretty early to adopt software solutions. The vast majority of EHRs on the market were designed or architected more than a decade ago. In fact, a decade-old EHR is still considered a relatively new entrant. And yet our view of what interoperability, user experience, ease of use, and connectivity should look like has changed dramatically in the last decade. 

EHRs generally in the industry are somewhat of an inhibitor to the ability to have true data liquidity and ease of interaction and interface. That’s one reason that Greenway and Greenway’s board is committed to developing a next-generation solution that is fully cloud native.

While the state of interoperability is embryonic, the vision for what it can create is well formed. The pandemic and various other elements of even recent legislation will force an acceleration of the view of how we ensure that the data is available where and when it’s needed for the best results, for both the patient and for the healthcare system overall.

Do you have any final thoughts?

Our focus is on supporting the ambulatory physician practices and community health centers. We’ve done a lot to help them in the present pandemic, including launching a new revenue cycle product. But they are really hurting. The ambulatory practices are hurting in a way that doesn’t grab the headlines as much as it does about the acute care.

Our customers need a lot of help to return to a new normal. That’s what we are committing to. But I really hope that as your readers read this interview, they realize that there is something else here. A healthy healthcare system in the US requires a healthy ambulatory segment, too. We need to ensure that they survive and do well beyond this pandemic. That’s our focus.

To all of your readers, just be safe and be well. We will get through this.

HIStalk Interviews Lissy Hu, MD, CEO, CarePort Health

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

Tell me about yourself and the company.

I’m a physician by background. I started the company to better bridge hospitals and the care partners that they work with, such as nursing homes, home health agencies, hospice, all the post-acute settings that patients will need after their hospital stay. We are in just over 1,000 hospitals, 180,000 post-acute care providers, and 43 states. It has been a pretty amazing journey.

How is the pandemic changing the relationship between hospitals and skilled nursing facilities?

People are realizing more than ever that nursing homes are critical part of the care continuum. These long-term care facilities, where we house our elderly and our vulnerable populations, are incredibly susceptible to COVID. A huge crisis is going on in nursing homes across the country. As a result, they’ve stopped admitting patients. They are scrambling for PPE just like everybody else and for staff to care for their existing residents.

But in American society and healthcare, these nursing homes are also short-term rehab centers, where they take patients from the hospital. That helps to keep the whole healthcare system flowing, so that that you don’t have bottlenecks on the hospital end. They don’t have any places to safely discharge their patients for rehabilitative care, especially for COVID patients, where they are in the hospital for a long time.

Consider a 50-something patient who has never had any rehab needs. Once they’ve been in the hospital for a couple of weeks and on a vent, they’re deconditioned. They are going to need rehabilitative care. The pandemic has made it clear just how interdependent hospitals and post acute-care providers are.

A lot of the hospitals we work with are strengthening their partnerships and their connectivity.  With some of the software that we’ve built between themselves and post-acute, they have been able to leverage some of those existing relationships in this time of crisis. It has been heartening to see hospitals continue to value their post acute-care providers.

On the other hand, being connected to these post-acute care providers, we see their EHR data. We see the spikes and deaths. Each of those data points is someone’s grandmother, someone’s parent. It’s just hugely, hugely sad.

Will the level of information exchange between hospitals and post-acute care providers change with this new level of dependence?

I’ve been on the phone with state and federal government officials talking about the pandemic response need for more support for post-acute care providers and more tools that help them. It’s not exactly in the area that I work in, in terms of our software that is connecting hospitals and post-acute care providers. But in those conversations, it is surprising that they are recognizing, for the first time, that these nursing homes play these dual roles. A lot of people think of nursing homes as these residential facilities. Awareness is building that they are also an outlet, a step-down unit if you will, for hospitals.

Prior to the pandemic, people were thinking about how to better work with their post-acute care providers on the hospital end. Because of things like bundles and ACOs, hospitals needed to think about the patient, not just in terms of their particular hospital stay, but their recovery period. I think we’re going to continue to see more of that with the interoperability rule.

One thing that a lot of people didn’t expect with the CMS interoperability role was mandating electronic notifications. Not only to the physician — CMS included skilled nursing, home health, and other post-acute care providers. That’s recognition that these post-acute care providers play an important role in the care continuum.

Here’s one example. When a skilled nursing facility transfers a patient into a hospital, they don’t know what happens to that patient. They’re calling the patient or calling the hospital to find out whether that patient is going to come back. Should they hold the bed, or should they not? When we built our software to be able to better communicate between the hospital and the post-acute provider, our infrastructure allows them to get notified about what actually happens to that patient. Are they just there for observation, or will they be admitted? That allows the skilled nursing facility to prepare.

That became even more important with COVID. The skilled nursing facility would send the patient back for testing into the ED. Maybe they would get tested, stay there for a couple of days, and then get sent back with one negative test. But with one negative test, because of how vulnerable that patient population is, the skilled nursing facility is still going to put that patient in an isolation room and use PPE. You need to know about that second negative test, which is when you can start to put the patient back into the larger residential community and start to conservative PPE.

We made some small modifications in our platform that transmits those lab results back to the skilled nursing facility. These skilled nursing facilities get confirmation that the patient is negative and can be moved out of an isolation room. Even small improvements in connectivity can have a big impact in terms of the skilled nursing facility and their ability to care for these patients, while also protecting all the other residents. I expect to see much more of that coming on to the other end of the curve with the CMS interoperability rule and in some of the requirements on the notification side. Not just the PCP side, but on the post-acute side as well.

Sometimes the biggest interoperability challenge involves integrating the received information into workflows. How do you see that working with ADT notifications?

It’s funny that even though I’m a physician who built a technology company, I always think that technology is probably just 50% of the answer, if not less. It may be a little bit heretical to say that as a CEO of a tech company. But the other big component realistically is thinking through the workflows. If people send notifications in a way that requires someone to log into a portal and view an event, you’re taking the nursing home out of their own workflow. That presents a huge barrier to adoption in terms of making the information usable and actionable for that skilled nursing facility.

We have 180,000 post-acute care providers on our platform, so we think that we’re in the right position to surface these notifications into the workflows of skilled nursing facilities and other post-acute providers . They are in our systems every day. We see them doing really practical stuff with this information, like deciding whether to hold the bed of a patient who has gone to the ED while waiting on confirmation that they will be admitted. The hospital benefits as well, since when they send a referral to that the skilled nursing facility for a different patient, the skilled nursing facility has a bed available because they aren’t holding one unnecessarily.

They are going to be able to use this information in practical ways. But it’s important that the information is delivered into their workflow rather than every hospital adding another place that the skilled nursing facility needs to log into and look at. It’s hard to do the right thing in using that information if you put barriers in place.

How has the company’s focus changed with the pandemic and what new requirements to you expect from customers?

We’re seeing more focus on electronic communication. For example, we have a product called CarePort Guide that helps patients and families make decisions about post-acute care. It has things like the quality scores, pictures, and virtual tours. We built that tool because even pre-pandemic, it was the patient’s adult children who were making decisions about where the patient would go. We’ve seen a huge spike in use of that platform because now hospitals don’t allow visitors. We’re seeing more usage because of the need to do virtual tours since nursing homes have also locked down.

Our tools allow the hospital and post-acute care providers to communicate. Instead of somebody at the admissions office leaving a phone message for a hospital nurse case manager, they can communicate bi-directionally since both of them are on the platform. There’s just a lot less friction. We’ve seen the number of electronic communications spike because the nursing home staff are no longer able to go into the hospital to screen these patients or to talk with them in person prior to receiving that transfer.

We’re going see, beyond just telehealth, more and more electronic delivery of care in a lot of other areas. Even in areas that people wouldn’t typically think about, such as the communication among the hospital, the post-acute care provider, and the patient who is making these decisions.

Since our platform connects hospitals and post-acute care providers, we are tracking patients from the time they enter the ED all the way through their recovery period. A lot of our customers are asking us to track COVID patients to understand how to prepare post surge. What will their recovery needs be? People didn’t really know. We are starting to aggregate data across all of the 1,000 hospitals that we work with and all of their EHRs — Epic, Cerner, Meditech, Allscripts, and all the electronic systems used on the post-acute care side. We are tracking something like 22,000 patients from the minute that they enter into the ED through their inpatient course, through their ICU course, through their post-acute course. We’re starting to see trends that are helpful for our customers as they are managing these patients across the continuum.

Do you have any final thoughts?

As we move into this new normal, we are seeing the interdependence between hospitals and post-acute care providers. Although the interoperability rule has been delayed for good reason, people will start to see this rule as being really important coming out of the pandemic, or going into the second wave of the pandemic. There’s a real need and opportunity to be able to share patient information in real time so that we can monitor and track these patients and communicate better with one another. That need is being crystallized in the heightened reality of COVID.

HIStalk Interviews Chris Klomp, CEO, Collective Medical

Chris Klomp, MBA is CEO of Collective Medical of Cottonwood Heights, UT.

Tell me about yourself and the company.

I’m the CEO of Collective Medical. We are based in Salt Lake City. We operate the leading real-time care activation alerting and collaboration platform in the country. Our objective is to stitch together otherwise disparate hospitals, health systems, post-acute, clinics, primary care, specialty care, accountable care organizations, health plans, and others to understand where patients travel in real time, identify those who are facing imminent but avoidable risk, and then activate the most appropriate stakeholders to intervene on behalf of that patient to prevent this bad thing from happening to him or her.

We are in use by over 1,000 hospitals and health systems and several tens of thousands of other providers of varying types, including every national health plan in the country, loads of regional plans, and accountable care organizations.

The results are pretty extraordinary. We start with ADT data, but we augment that data with all sorts of incremental data types. Not for purposes of moving that data from point A to point B, which we think is the provenance of health information exchange, but instead leveraging that information in a secure and privacy-compliant manner to help providers intervene with those patients whose needs may go unmet.

Our objective is to improve patient-specific outcomes at the lowest possible cost. We find a tremendous amount of opportunity in the face of medically unnecessary, avoidable utilization.

How will the 21st Century Cure Act’s push for interoperability and ADT notifications affect health systems and medical practices?

A number of provisions within the rules are exciting. We are particularly focused on the recently modified Conditions of Participation, which require hospitals in their several forms, principally acute hospitals and critical access hospitals, to make downstream providers — primary care providers, post-acute facilities, and skilled nursing facilities — aware that a patient has been admitted or discharged. That’s a benign and simple ask, and yet it’s powerful.

We and others already facilitate this type of information awareness. But if you think about it in its most essential form, we as a country charge primary care providers with quarterbacking the care of their patients and coordinating that care across specialists in different acute and post-acute settings. Yet it’s as though we have been tying at least one, if not two, hands behind their backs while expecting them to call the play and throw the ball. They don’t even know when their patient is sitting in a hospital or why, and therefore they are not well positioned to intervene.

These rules are designed in a lightweight manner, right now with not much of a stick, for hospitals to just try a little bit harder to do more to help downstream providers coordinate care more effectively, to take the handoff  from the hospital in a timely manner. I’m sure there will be more to come, where over time, additional data will be required to be shared, perhaps discharge plans, test results, or others. Penalties will probably be instituted, so that stick may get a little bit bigger. But the carrot is also getting bigger as we increasingly shift toward value-based care arrangements. All of this is in the spirit of collectively caring for patients, collectively caring for our most vulnerable members in the community.

This is highly aligned with the strategy that we have been pursuing as an organization for many years. Our name is not by happenstance. We believe that in the concept of better together, as care teams collectively care for one even if they represent different organizations or have never met one another, they are united by their common stewardship for that single patient in that moment. That requires some level of data and clinical interoperability to align their efforts in the most efficient and effective manner. 

The rules are simply trying to remove a few barriers and provide a little bit of additional encouragement, in a light-touch manner, for hospitals and providers do this more effectively. We are excited about that.

What care coordination challenges or needs will be driven by the adoption of telehealth?

We have observed as a country this massive, singular, step-change function, where we shuttered brick and mortar care. I needed to go to a physician recently. All was fine and it wasn’t a big deal, but at the time, it was reasonably urgent and not something that telehealth could appropriately address. I had to pull out all of my powers of persuasion and negotiation to get seen by a provider in person. My family and I have been fortunate to be able to strictly self-quarantine over the last couple of months, and while recognizing that not everybody has that advantage, we were able to make that attestation. The provider acquiesced and agreed to see me and I was grateful for that.

Broadly as a country, hospital revenue is down between 40% and 70% because volumes are down. It is not just electives that have been postponed, but also anything that is essential but non-urgent. Some of that it is being pushed to telehealth, but emergency and inpatient volumes are significantly down.

I would not have expected this step-change function to have occurred without massive external or forcing function externality, and yet it has. It is showing us that many things can be done remotely. Telehealth is here to stay in a much more significant way.

As a result, sending a bunch of faxes and working the phone lines with telehealth providers is not a scalable or cost-effective solution. That puts more emphasis on the need for not just technical interoperability — to get the data to those providers who are not necessarily connected directly to an originating provider’s office, hospital, or health system — but to also also understand what they are recommending and doing. Then, drive that workflow back to the community, to whoever is going to pick up the ball and continue to provide care for the patient, both virtually and in a brick-and-mortar location. It’s both technical and clinical interoperability.

At the same time, I worry, even in the absence of good data or studies, that if you postpone something that needs to be done, it often gets worse and more costly. If you have been diagnosed with cancer or are delayed getting a mammogram, the longer you wait, the harder it is to treat. I worry about that. We have no data, so we don’t know the implications. If this lasts just 60 to 90 days, hopefully the damage will not be particularly acute, and telehealth will have been able to fill that gap along the way. Clearly they are seeing their volumes surge as a subsector. But if we continue to have waves of the pandemic and a vaccine doesn’t come into play, we may find that we have a bigger issue as a country, which is worrisome.

Governments and public health experts are trying to manage the pandemic with voluntarily emailed hospital capacity worksheets. What would be the benefits and challenges involved in providing a real-time view of cases and capacity?

I don’t think that the federal government needs an identified surveillance system that understands where individual patients are going, why they are there, and what care they are receiving. That feels like a big brother surveillance state that as a country, certainly as a citizen and as a patient with my own patient rights, I don’t want. I don’t think that we as a country need that. I have not heard anyone at the state or federal government level ask for an identified surveillance system, and certainly we are pretty close to a lot of folks in state and federal government.

The ask has been for a de-identified solution that would allow not just capacity planning, but real-time evidence of what is happening with disease’s progression. As we ramp up the volume of testing, it will look like we have a second wave of the pandemic. That will lead to all sorts of potentially poor policy decisions, because we now think that there’s an onslaught, when in fact there is not. Nothing has changed except our improved ability to measure.

If you can’t rely on testing until it’s at some sort of a steady-state stasis, with sufficient scale to accurately depict the representation of the infection fatality rate and case fatality rate, what then might you use as a proxy? ADT data is incredibly valuable in that regard. We can understand in true real time — on a de-identified basis that fully protects patient rights or that is even rolled up to the metropolitan statistical area or state level – if we are seeing increased or decreased volumes of both suspected and confirmed cases. We can pull in the lab data to augment this ADT data, which we are doing for a collective of several states across the country on a de-identified basis. 

This is not surveillance, but rather simply an aggregate macro view of what we are seeing from a trending perspective. It allows public policy leaders to make decisions about how to allocate scarce resources, such as ventilators and beds.

What is an entirely unacceptable and insufficient manner would be collecting things by paper, email, and Excel file. There are systems in place right now, including in government, that are trying to rely on that information. The resulting information is, at best, patchy, incomplete, and delayed by many days. We are hearing this from government leaders.

Just like we said about primary care providers having their hands tied behind their back, imagine being a policy leader. You are trying to decide if you should ease social distancing, reopen restaurants, or start to widen the aperture of what constitutes an essential business, because you are also worried about people starving out from massive economic decline. Yet you have, at best, a patchwork set of data that is not representative of what is actually happening with this hidden enemy. That’s a really difficult position.

You could make better decisions with a a highly privacy-compliant solution that has nothing to do with individual surveillance, but that instead shows de-identified, aggregated suspected and confirmed cases with an accurate denominator of total volumes presenting to an emergency department or inpatient care setting. That’s what is being asked for by folks in federal and state government. As a citizen, that makes me feel a lot better.

Do you have any final thoughts?

The pandemic marks a turning point in healthcare along many dimensions. It has many silver linings. States will be better enabled to build public health infrastructure that we previously could only dream of. We have a catalyst to understand the importance of this and to understand the importance of preparation. 

We need to align on a set of clear objectives. Those should obviously be patient safety and outcomes, provider safety, and guiding public health response to inform policy to allocate scarce resources broadly. But the very nature of our response  is showing the entire country the need for a more comprehensive and logically tuned health IT infrastructure that works together and is not operating in silos, whether it’s data silos, provider silos, or equipment provider silos. As a country, we need to come together. Slowly, I think we are starting to see that, even though we’ve had some gaps in our response efforts.

I’m hopeful that we will make the changes we need to make once we move past the acute or attenuated point of this crisis. A vaccine may not be our answer. We may go back to old-fashioned masks and social distancing to starve the disease out. Regardless, we need good data to understand how to proceed. That will happen only if we come together and continue to work on things such as what is being promulgated in the 21st Century Cures Act. 

I’m hopeful. I’m optimistic. We are a country that tends to rise together in times of crisis. I have no reason to believe that this will be any different. We are certainly seeing evidence of that across the country with all of the stakeholders with whom we partner.

HIStalk Interviews Krishna Kurapati, CEO, QliqSoft

Krishna Kurapati, MS is founder and CEO of QliqSoft of Dallas, TX.

Tell me about yourself and the company.

I’m the founder and CEO of QliqSoft. We’ve been in business for eight years. I have been tech entrepreneur for over 20 years. I started a couple of companies that were successful, one in communications and the other in security. That’s where I found the epiphany of having a secure communications company in healthcare.

How has demand for your virtual visit solution changed in the last few weeks?

Coronavirus stopped the healthcare system and its providers from seeing the patient in a personal, face-to-face setting. That has driven everybody to find ways to address that problem.

We had a simple solution that allowed quickly onboarding patients. The challenge in telehealth is always adoption by patients. The providers have the tools, but patients don’t want to download an app or get to a desktop. A key healthcare requirement with COVID-19 is ease of use, and providers were looking for a simple solution that allows them to reach their patients effectively. That’s one reason that tools like ours quickly sprung up and got lot of traction in the marketplace with providers.

From the demand point of view, we have never seen such a huge uptick in the use of telehealth. One health system is delivering 10,000 to 20,000 video visits in one day. That is unheard of. It used to take  a year or more for somebody to do that kind of volume, and how they’re doing it in one day. Some of our customers used 365 days’ worth of video minutes in just one week. There is a huge demand. There’s a bunch of solutions, but we offer something simple for providers to reach patients.

What factors distinguish one virtual visit solution from another?

Everybody is going virtual. The time to onboard and train is important. How fast can you onboard a clinic, practice, or health system? Then, how can they customize it to meet their needs?

A small practice and a large practice have different requirements. A dermatologist has different needs than an internist. They all want to get on board faster, but they also have specific requirements.

Traditional telehealth solutions have been built around monolithic, large implementation needs, and those do not help in rapid fashion. We built, with our Quincy chatbot and Quincy video visits platform, fast tools that let you onboard a provider, bring them up on video visits, and customize it to meet their needs. The solution needs to be easy for the patient, but it also must allow getting providers online and using the tool quickly.

Has the pandemic changed the long-term strategy of health systems that were using third-party telehealth services before, but now are offering virtual visits with their own providers?

Face-to-face visits will not go away after COVID-19. The need to see a patient face-to-face and give them advice will come back in a big way. But providers will offer services such as follow-ups, post-op visits, and other ancillary services virtually, along with services that have traditionally been offered by all-in-one telehealth solutions. As a patient, you trust the provider you know and who treats you. That has been a big problem with the all-in-one solutions all along. That option was OK, but not great.

When you have traditional providers offering the same solution, the patient gets better access to healthcare from wherever they are. They don’t have to leave the workplace. They don’t have to travel 50 miles from a rural area.

COVID-19, if you see a silver lining, has shocked the industry to go all in and see what the experience is. Some providers may hate it now, but I’ve talked to several of them, my customers and my friends, now that they are using the solution. Some wonder why they weren’t doing it before, saving time for themselves and the patient. Even some specialists, like orthopedic surgeons, are using it for post-follow-ups in a way that they were never using it.

The industry has shifted overnight in being forced to use it, but in turn, there’s a lot of lessons and a lot of best practices. The new way of doing business is not going to change.

How are health systems using chatbots?

Healthcare is good at using calls, faxes, and other technologies for inbound stuff, such as referrals or patient access. These technologies existed for a long time, and suddenly there is pressure on them. Call volumes went up. People are always on text and they know how to use it. The chatbot gave initial productivity to health systems that wanted to tackle call volume, to offload it and get people the appropriate help. The chatbot can send a form, send a survey post-visit, collect information that humans had traditionally collected, or serve in the arcane way of answering services.

Chatbots already had found their footing in traditional support and sales models in other industries. Healthcare has now found their value in this tough time when volumes are so high.

Once healthcare organizations have adopted the technology and become comfortable with the outcomes, they will next use it in places where it makes sense, such as post-op surveys, pre-op information gathering, and helping patients who are really in need. It’s the 80-20 rule — 80% of patients can be served by the chatbot.

COVID-19 has accelerated technology adoption, both for virtual visits and for using automated responses and navigating patients using chatbots.

What other technologies could see a usage uptick?

Think about physician pain points before and after COVID-19. They want to continue to serve their patients effectively and efficiently. How can they do it? What are the tools and technologies beyond the EHR?

It has to be a mix of digital and face-to-face, but beyond chatbots and virtual visits, there’s a need for other AI-based tools, such as for transcription and other technologies that can simplify the problem of EHR productivity. The timing is right, with everything becoming virtual.

Technology would go a long way toward furthering patient care if it could transcribe the physician-patient communication and immediately put a 30-page document into the EHR without the physician typing anything. The end goal should be to allow the physician to interact with the patient face-to-face without worrying about the technology.

How will the company’s direction change after we find a new normal?

Our goal is to help customers to achieve better outcomes and better efficiencies. I have been a strong believer in these two technologies for the last four to five years. Before that, it was secure messaging. We’re going to double down on our efforts to continue to serve our customers and innovate to meet their needs. A technology evolution is starting, and it will create requirements and needs that we can’t anticipate.

Think of a new product being introduced, such as the first IPhone, versus where it is today. We will see a rapid evolution of products towards the complete virtual value for healthcare. Community-wise, for a country or as a world, this will be a good outcome in the long run. If another pandemic happens, we will be prepared. These technologies will stay and evolve rapidly and we want to be part of it.

HIStalk Interviews Jeremy Schwach, CEO, Bluetree Network

Jeremy Schwach is CEO of Bluetree Network of Madison, WI.

Tell me about yourself and the company.

Bluetree is about 400 people strong. We help the largest healthcare organizations in the country tackle their biggest problems. About half of our folks come from an IT background, specifically Epic, and the other half comes from a provider background and really understands the business of healthcare. We put those two things together, we figure out what our clients need, and then we jump on it.

How will current events affect the consulting business, both now and in the future?

A lot of our work is core IT related. In some instances, we are as busy or even busier in certain areas. In other instances, we are helping with the big strategy projects that our clients have pushed.

For the most part, we haven’t seen anything totally cancelled. There’s a lot of instances where our clients are saying, and rightfully so, “We need to stay focused on the crisis at hand.” They are dealing with what the rest of the world is dealing with from an economic standpoint, trying to figure out how to prioritize.

Certainly the bottom isn’t falling out. We are taking a long-term view. We’ve seen new opportunities around telehealth. Organizations have moved incredibly quickly for their size compared to how long it has taken historically to get big enterprise projects done. We feel good about the long term and we know that we need to make sure that we are weathering the storm like the rest of the world.

Epic, Cerner, and Meditech have turned around a lot of COVID-19 related changes quickly, ranging from terminology updates to mobile hospital support to telehealth integration. Are customers taking advantage of these new options?

I would say yes. It’s amazing how focused the mission becomes when you are dealing with something that is as acute, and in some cases as devastating, as the current crisis. It ranges from vendors who are putting their best foot forward to clients who have accelerated two-year projects to get them done in two weeks.

I’m impressed with our own folks, who have gotten creative in tough situations. We were remote-first to begin with, so we had a little bit of an advantage. But no one was prepared to take on full childcare and also support their clients who were, in some cases, as busy as ever fighting on the front line. A lot of people in healthcare deserve a ton of credit as their mission comes into focus in times like these.

Are your clients worried about cash flow after being forced to temporarily shut down their most profitable services?

Everybody is concerned, in part because it’s hard to plan. How long does this thing go? When do we start letting patients come back in? “Elective” is the wrong word considering that no one wants to get surgery. At some point, you have to let patients back in.

That is made more difficult by the regional nature. We work with a 160 clients across the country, most of them large. You can take an inner city hospital that is battling this thing on the front lines. Then you go two hours in any direction and you can find a hospital that has had few or no COVID patients. They’re still planning for it, so they have the the same economic hardship from reduced census and lack of profitable electives. While the regional nature is bizarre, everybody is in the same economic quandary.

What technologies have been recently embraced that will stick after things get back to some kind of normal?

We are seeing the same things that you listed in your post. A lot of digital tools. Chatbots getting deployed more widely.

What is interesting is the amount of infrastructure that is required to stand up something like telehealth. Most people look at telehealth as the tool itself and the availability of physicians. There’s an underbelly infrastructure that is a big part of the heavy lift. For example, we take patient calls for some of our clients and have expanded that service because our clients need it. But regardless of the telehealth tool, a whole demographic of patients are just not going to be comfortable using it. It’s basic things, like opening the right browser and getting webcams set up. We’ve seen this huge spike in patient calls as a result of some of these new tools, and it’s not even COVID related, necessarily. You have to build an infrastructure around these things.

We expected our clients to kick the can on some of our big strategic projects to keep everybody focused. We haven’t seen that happen. In some ways, our clients are even more focused on this consumerization of healthcare. We do a lot of work on patient access centers. Because we are accelerating these new tools, clients are having to create the customer service infrastructure that other industries have built up over 10 years, but that is new to healthcare. We are seeing a lot of demand, and these hard, big projects that impact tens of thousands of users continue to move forward.

If you want to put in cool new texting apps or the latest fancy bell and whistles from your new startup, you need that baseline infrastructure. A patient has to be able to call in, talk to somebody about financial counseling, get a nurse in real time, get their prescriptions refilled, or get an appointment scheduled. Now you are adding telehealth volume and chatbot questions to that mix. Our clients are accelerating building that core infrastructure, because otherwise it’s hard to do anything in the consumerization patient world. It was surprising how quickly something so strategic kicked into high gear.

What interesting changes are you seeing from Epic and other vendors?

A lot of what clients are leveraging now existed in the past. We have just re-prioritized in healthcare. Vendors haven’t released a lot that is brand new or that was spun up quickly, but certainly they have been incredibly available on the analytics front. Maybe one of the surprising outcomes was Epic and other vendors working with the federal government to figure out, because of their large footprint, how to help from an overarching view of what’s happening in the country. Vendors weren’t necessarily doing or even feeling comfortable doing that historically. The current times demanded that, so they stepped up to the plate.

MyChart tools, chatbots, and telehealth all existed. It was a matter of prioritizing and then building the infrastructure.

What types of companies will be best positioned to weather the crisis and emerge strong on the other side?

We were acquired by Providence in July, which gave us a longer-term view. Our approach has been that current events are changing healthcare dramatically, and in some cases for the better. When we come out of this, the changes that we are already feeling will be accelerated. The opportunities in healthcare continue to grow and are maybe even being expedited by the current crisis. Anybody who takes a long-term view is going to be better positioned. We are doing everything we can to keep the team together, but our goal is to make sure that when times that are slower, we take advantage of the opportunity to build and focus on what our clients need now.

Your readers will roll their eyes when I say this because every CEO has to say this, but I personally feel incredibly fortunate to be attached to Providence. We are a small company that has an opportunity to make a big impact, because even as a small company, we work with some of the largest, most influential healthcare systems in the world, and on some of their most strategic projects. We feel fortunate to be in that position.

As a small company, you’re wondering about your long-term view and whether you can go about it as a solo practitioner. It is doable, but incredibly hard and increasingly rare.

You wonder if you  should take the financial buyer route, such as private equity. You know the pros and cons of that. One of the cons is that your company will be sold every three to five years by an owner that really cares about just one thing, which is their prerogative and goal.

Then you have the strategic, who will look at how to leverage the skill set, the people, or the customer base. 

Providence came to us in February and basically said, there’s a fourth option. We have this 170-year-old, mission-driven non-profit with an enormous footprint. We are one of the largest Epic clients on the planet. We want to keep delivering this vision for another 170 years. We know healthcare is changing, so we want to do things differently.

That was the Providence sales pitch to us. We could help them modernize and innovate, but we could also gain an opportunity to do things differently, remain independent, and work within a new commercial entity that can go out and do bigger things. We get the platform to do what we already do, but with a bigger impact.

We are nine months through it and it has been incredible. They have been an amazing partner because they aren’t a PE shop or a traditional strategic. They are totally different and they have been true to their word. We are fortunate to have them as a partner.

The initial announcement said that Providence planned to build a $1 billion business from their acquisition of Bluetree, Engage, and other companies. How is that working and what is the strategic direction?

The vision has been super clear from the beginning. It’s not easy to do. They’re a large organization. Those wheels have been turning for a very long time.

Before the acquisition was finalized, I had a chance to sit down with Mike Butler and Rod Hochman, the president and CEO. They said, tell me one other organization that is 170 years old, founded by a group of women, with our scale, that cares deeply about a non-profit mission, and that has survived for all these years because of that vision. Rod laughed and said, don’t think too hard about it because there isn’t any other.

They are in a unique position because of longevity, their 114,000 caregivers, and the skill to do it differently. Because of that vision, it’s been clear what we need to build. One of their guiding principles was that this would not be Bluetree and Engage folding into Providence. They could build that themselves. This is taking advantage of their scale and all of the smart people they have to build something different.

What’s been most surprising to us is that a consulting company, we’ve got folks across so many clients. We’ve got a pretty good long view of what’s happening. We felt like we could make a difference for Providence, and that’s important.

The crisis has shown us, in a short period of time, that Providence has as much to give us as we have to give them. Their response to the crisis has been unbelievable, that an organization with that level of scale could move that quickly. They had the first confirmed COVID-19 case in the US, so they had a head start. Not only did they stay focused and organized, they allowed us to come in and learn from them as they were going through this. Because they have this amazing non-profit vision, we posted their learnings publicly. Our website has a COVID-19 page and a lot of the content was from Providence’s learnings.

We did a deep dive as they were building their analytics tools across their large geographic regions and we learned a lot from them as they looked at cash, preserving cash, and accelerating cash as we come out of this. We got an inside view, the chance to exchange ideas, and then the opportunity to publish it quickly because it was good for the world. That drove home the fact that this is such an unusual partnership in healthcare.

HIStalk Interviews Ed Marx, Chief Digital Officer, The HCI Group

Ed Marx, MS is chief digital officer of The HCI Group of Jacksonville, FL.

Tell me about yourself and your job.

I started my health career at age 16 as a janitor in a healthcare facility. Since that day, I knew my purpose in life was in healthcare. I didn’t know how it would manifest itself. Certainly not as a chief digital officer for a major global organization.

What does a chief digital officer do?

My objective is twofold. One is to make sure that we as an organization digitally transform ourselves. I always say that you have to eat your own dog food. If we are going to consult or sell or whatever to customers around the world, we had better be able to use ourselves as the number one use case.

Second is to take those same learnings and teach people how to leverage technology in order to see digital transformation in whatever their specific objectives are. It runs the gamut. 

What is digital? I can give you the formal definition as I see it, but really it’s a natural evolution of technology, but centered around experience. Helping organizations achieve that and to continue their evolution to enable the organization’s objectives.

What organizations are doing digital transformation well in healthcare?

I give credit to everyone who is doing anything, because at least they are moving the needle. I’m going to answer your question specifically with a couple of the obvious ones, but in addition to that, a lot of small hospital systems are doing good things.

We always highlight the bigger ones that have more resources. Certainly you talk about the Mayo Clinic and Cleveland Clinic. They have done a lot for a long time to continue that evolution, and now revolution, of technology enablement. Those are a couple of organizations that are doing a really nice job.

The impetus of the situation that we are in today is only going to help everyone accelerate that journey. That journey has been slow, especially compared to other industries. But we have an opportunity to catch up and see the fruition of all of that technology can do to enable superior clinical care.

Are health systems looking at new entrants like Walmart, Amazon, and Walgreens that have created new consumer experiences and just throwing up their hands and say they can’t match them, or are they choosing specific aspects they can implement?

We have new entrants because those companies are looking to continue to grow their margin. They look at the percentage of GDP that healthcare makes up and think it’s an area that they should focus on.

But a second reason, which maybe never should have happened, is that few of us were leveraging digital transformation and changing the whole experience. You’ve seen that in other industries. People get upset when you compare healthcare to other industries and I know healthcare is different, but from a technology point of view, you saw disintermediation of multiple industries by new entrants who said, we’re going to be more about the experience. We’re going to use automation and “digital,” quote unquote. We can do it at a lower cost point. Those sorts of things.

Whether it’s big tech or it’s retail, they are seeing the same thing. Not only is there a huge opportunity in terms of what the spend is, but in healthcare, we haven’t done it necessarily the best way because we weren’t forced to. Now we have globalism, consumerism, and retail giants who are all focused about the experience of big tech. That’s why we’ve seen this happen.

We need to learn quickly. What is the secret sauce that a retail giant might bring in terms of the experience? That’s really it. I keep using the word “experience,” but it’s really a focus on the experience. Then enabling all the technologies that they are using on a day-to-day basis to make their life easier. That’s what we need to learn. 

In some cases, we need to partner and we should partner. Sometimes it’s better to partner and do good things in the world than to sit back and watch your business be disintermediated.

Sometimes it’s better to be second in learning from the mistakes made by whoever got there first. Will we see organizations leapfrogging that first generation of consumerism?

That is happening with some forward-thinking hospitals and health systems. They are taking the time to analyze what’s going on in retail, how they created those new, enhanced experiences, and taking some of those learnings. We’re seeing that now. I’ve heard of many health systems that are working on their basic patient portal, and you know those aren’t about the experience. It’s a good start, but again, years behind what other industries have been doing.

Some forward-thinking hospitals and healthcare systems are keeping that as the foundational base because of all the integration it has. They they are building layers on top of it that get all about the experience. So I do think you can …  I don’t know if it’s actually leapfrogging, but at least keeping pace.

The leapfrogging might happen in partnerships. It will be hard for a healthcare organization to compete with the capital and innovation mindsets that some of these outside entrants bring, whether it’s retail or big tech. I would see it very challenging for a healthcare organization, especially an average healthcare organization, to bring together the mindshare and the capability to leapfrog, but I think you could leapfrog if you selected a good partner.

How will the coronavirus pandemic and the economic shock that accompanies it affect healthcare’s digital transformation?

I’m thinking two or three things, and I’ve thought quite a bit about this in the last several days. One is that it’s going to be the pure acceleration of everything we’ve been trying to do, the whole virtual care continuum. I came from a leading organization and 1% of our outpatient visits were virtual, with a goal of getting to 50% in four years. I haven’t checked back, but I bet they are pretty close to 50% now. 

Part of that stack, too, is healthcare at home. This was another thing that I put out there, that 25% of inpatient visits will be at home in the next four years. I get the feeling we’re going to get there much quicker.

Those are two examples. I think those are permanent. I don’t think that after this, we’re going back.

Another is a new way of work. I’ve been a big proponent of working from home as a way of work for 10 years. We’re not going to go back. There is no reason, ever, to travel to go use a computer. I’m sure some companies and hospitals will disappoint me, but those days are gone. That will do tremendous things for healthcare in terms of taking out costs.

These concepts of virtual care and a new way of work will come together to change everything. Why would you ever want to go and sit in a waiting room? Those two changes are going to be permanent.

How will the possible new emphasis on public health change the health IT discussion with regard to interoperability, analytics, and aggregating patient data?

I’m less optimistic on that one. I hope this brings our country together to be more serious and more intentional on public health. It took this crisis, this terrible situation, to make it happen. You bring all these smart people together and the resources that everyone has with public-private and we can do amazing things. We should have done it a long time ago.

I’m hoping that this is a catalyst that changes our public health for good. That we become a more healthy country, that people take wellness more seriously and more personally, and that our country is able to be predictive and preventative at the same time so that nothing like this could ever occur again.

Do you have any final thoughts?

I hope that my fellow CIOs and chief digital officers continue to lead the trajectory that we are on. I’ve always been critical of myself and my peers in terms of why we lag behind other industries. Now, because we’ve been given clarity, focus, and budget, I’m hearing from a lot of my colleagues about all the awesome things they are setting into motion now. May it always continue. May we take that leadership mantle and not tarnish it, but brighten it for the good of our patients and the communities that we serve.

HIStalk Interviews Patrice Wolfe, CEO, AGS Health

Patrice Wolfe, MBA is CEO of AGS Health of Newark, NJ.

Tell me about yourself and the company.

I’ve been in the healthcare industry for over 25 years, with the majority of that in the HCIT space, including revenue cycle management. RCM is an exciting and growing field, and if you do it right, you’re improving the financial health of provider organizations, which frees them up to redeploy resources that can be focused on patient care.

AGS Health is a revenue cycle outsourcing company that provides A/R management, coding, and analytics services to major health systems and physician practices, as well as to billing and EMR vendors. In 2019, we managed over $35 billion in A/R and coded over 25 million charts. We have 6,200 employees in the US and India, which is pretty amazing for a company that was founded in 2011.

What is the business environment of RCM and how has it changed over the years?

It has changed a lot. Given the penetration of EMRs and associated technologies, a lot of the manual effort that was needed to validate patient eligibility, submit claims, post payments, and reconcile remittances is now automated. In the past, the vast majority of A/R was payer-related, which just isn’t the case today. High deductibles are here to stay and providers are struggling to capture every dollar. 

The basic mission of RCM hasn’t changed – to optimize the speed, accuracy, and efficiency with which revenue is maximized and collected.

The revenue cycle is very complex. Too much so. Different departments frequently handle different parts of the cycle, which means there may be no real coordinated strategy for RCM. There are a few things I find promising, though. The industry is trying to bring as much as possible up to the front of the revenue cycle, such as advanced eligibility verification and patient liability estimation prior to the patient showing up for care. It’s a lot easier to collect a payment when you’ve told the patient in advance what they will owe.

Robotic process automation, or RPA, is eliminating low-value work from the rev cycle and driving greater efficiency. I think we eliminated about 80 FTEs of low-value work last year just using RPA, and our teams are doing more rewarding work as a result. A lot more can be done on this front.

Areas like coding used to be focused on maximizing the completeness and accuracy of clinical information for billing purposes.  Today, we’re seeing new and innovative uses for this data, which include risk-based analysis, provider scorecards, benchmarking, and analytics.

RCM is highly influenced by payer policies. I sit on the board of a large payer, so I see the challenges on that side of the equation also. There are a few friction points that I think are problematic for both parties. First, claim denials have been rising, which creates a lot of work for providers and vendors like us. Second, prior authorizations are labor intensive and remain stubbornly manual. We have a lot of work to do as an industry to resolve these issues.

What effects on health system RCM do you expect to see from coronavirus-related economic slowdown?

We are seeing the impact of COVID-19 in many areas right now. This is so hard for the provider community. In the last week, providers are canceling all elective procedures. That has an immediate impact on revenue, not to mention access to care. Some payers are shutting down call centers and stating that claims payment may be delayed. We use the call centers on behalf of our customers to resolve payment denials and delays, verify eligibility, and check on claim status. Limiting our ability to do that impacts revenue, not to mention the resultant lag in overall claims payment.

Providers are experiencing workforce shortages due to staff illness, inability to work from home, or reprioritization of work tasks. This is going to get worse. We are trying to help as much as we can from a staff augmentation perspective.

The administration approved some Section 1135 waivers to improve access to care, such as wider use of telemedicine, and allowing Critical Access Hospitals to have more than 25 beds. That’s great, but it’s confusing to both providers and payers as to how to operationalize these changes and ensure accurate reimbursement. I fear this is going to be a big mess.

Also, while new coding changes have been approved for COVID-19, it will take a while for provider systems to be updated with these coding updates, which translates into increased coding denials.

What are the benefits and challenges involved with managing a highly educated, technically savvy global workforce of six thousand people?

You forgot millennial. The vast majority of our team in India is under 30 years old, which is really interesting. I get asked for a lot of selfies when I’m there.

Regarding the benefits, as you mentioned, our entire team in India is college educated. They are open-minded, comfortable with change, and very ambitious. I do monthly live chats with our various locations and I hold quarterly focus groups when I’m in India. I get many questions about career progression and company strategy. These are people who can see themselves as leaders and problem solvers, which is exactly what we need in such a high-growth company.

In addition, almost 50% of our overall workforce is women, which is exciting for me.

The challenges of a large, global workforce really are around communication, training, and career paths. We are high growth, so things are changing all the time. That means I have to over-communicate on many topics and via many different methods, as do the other leaders.

We hired over 2,000 people in 2019, so grounding them in our business is critical. We have an incredible hiring and training infrastructure that can adapt rapidly as we add new clinical specialties and customer types.

I mention career paths because, as I said earlier, we have a lot of young, ambitious people who want to grow within AGS Health. We promote through the ranks as a regular practice. In addition, several people from our India team have relocated to the US to serve in customer-facing roles with amazing success. It’s been a win-win and we plan on expanding this program.

What I’ve come to realize is that, while revenue cycle outsourcing sometimes leads to job loss in the local community, we’re frequently doing RCM work that has been put to the side in hopes that someone in the organization will get to it eventually. For example, we do a lot of small-balance collections, maybe accounts of less than $1,000 or even less than $200. It makes financial sense to hand those to us because our labor costs are so much lower. These activities generate real cash for the organization that otherwise might have been written off. There are other examples like this around credit balance resolution and denial management.

Another challenge we’ve faced in the US is the labor shortage in both rural and urban areas, where things like clinical coding expertise may be hard to find or highly competitive. Even with computer-assisted coding tools, trained coders are still a critical part of the RCM process. In this part of our work, we are supplementing the teams our customers already have in place.

HIStalk Interviews Jeffrey Wessler, MD, CEO, Heartbeat Health

Jeffrey Wessler, MD, MPH is a practicing cardiologist, assistant clinical professor of medicine at Columbia University Irving Medical Center, and founder and CEO of Heartbeat Health of New York, NY.

Tell me about yourself and the company.

I’m a cardiologist by training. I started Heartbeat Health three years ago with goal of bringing a virtual care model to cardiovascular disease. Virtual care has evolved from telemedicine only as a platform, then urgent care chatbots, then some of the singular disease verticals such as diabetes. Now with Heartbeat Health, we have a chance to take on some serious disease processes, such as cardiovascular disease.

Little of a cardiology practice’s work is preventative, right?

That’s right. The majority of cardiovascular care happens after patients get sick. They get referred into the system after they have had a heart attack, uncontrolled blood pressure, or resistant symptoms. That made sense 20 years ago, when we really did need to focus our resources on treating those who had advanced disease.

But we’ve gotten pretty good at that as a field now. The advanced treatments are amazing and they work really well. The next phase, and where the ball is now, is now to keep people out of that advanced disease, emphasizing early disease management and prevention. That is the huge missing component with the care system.

Standalone healthcare apps tend to move the overall needle very little, so you have integrated your platform with your cardiology practice that provides the hands-on component. How do you see the company scaling?

What makes cardiology different than, say, weight loss management or exercise management is that these are really sick patients who need physical care. It’s this hybrid model of virtual when you can, digital when you can, but then get patients to the right care at the right time when they need it. 

By that, I mean the physical care environment for diagnostic testing, in-person evaluation, and hospitalization if needed. Being able to navigate between those two settings is really not done in the market right now. That’s our sweet spot — how to get people to the right place when they need it and everything else managed via the app.

You are offering services to employers and individuals. From the individual’s perspective, how would that work for someone who doesn’t live in New York City?

The best way to think of the New York office is as the test kitchen or the R&D lab for our clinical experience. But across the country, you would download the app, go through the risk assessment and data collection phase, undergo a tele-visit to speak with the doc and discuss the specific results — what the risk factors are, what they mean, and what the necessary next steps are. Then we would get you to a Heartbeat preferred partner who can do a stress test or arrhythmia monitoring as needed, then get that information back into the app for ongoing management.

The physical care happens very successfully in cardiology across the country. It’s just that too often, the wrong patients are getting to those doctors. By that, I mean not necessarily the right time or the right level of patient getting to the right specialist. That’s where we step in and say, it doesn’t matter where you are — California, Nebraska, Florida – the key step that we do is getting your data, interpreting it, organizing it, and then telling you and showing you where to go.

Do cardiology practices see Heartbeat Health as a competitor or a potential partner?

As a cardiologist, I’ve given a lot of thought to this. My goal is to become a partner for the highest quality cardiologists across the country. I have incredible respect and admiration for the level of work that’s being done. I want to make their practice habits better, faster, and easier, to trim some of the inefficiencies and administrative burden of what happens when you get the wrong patient and have to figure out parts of the care model that you’re not necessarily best at. Let’s focus you to get exactly who you want to be as a cardiologist and get you to do your best care. In that sense, I think Heartbeat really is a friend and a partner rather than taking business from them. We’re helping to augment their practices.

Will you integrate wearables, EKG, and monitoring solutions?

We are leaning heavily into the wearables and the device landscape. This is such an exciting part of the field right now. We have all of these consumer devices — the Apple Watch, AliveCor, Omron blood pressure cuffs – and cardiologists don’t really know what to do with that information yet. There are now hundreds of thousands of patients with Apple EKGs who are asking, what does this information mean?

This plays a role in how we find the high-risk individuals based on those wearables, identify what that information means for their care pathway, and determine when it’s relevant. This is a layer of service that is being provided on top of the devices to cut out some of the unnecessary data, focus on the relevant and important ones, and then use it to help people and help patients get into the right care.

Atrial fibrillation is probably the highest profile cardiac condition now that consumer devices like the Apple Watch and AliveCor issue warnings to users. How do you manage those newly worried consumers?

This is a very hot topic right now. You are wise to be identifying it as a real issue. The first answer is, we don’t know yet what to do with asymptomatic patients who are being diagnosed with AFib because of an Apple Watch or an AliveCor. All of the guidelines for stroke prevention and heart rate and rhythm control have been done in patients in whom we know that the atrial fibrillation is causing problems. That is mainly symptomatic patients, those with elevated stroke risk due to age or comorbid conditions, high blood pressure, diabetes, and prior strokes. These patients are fundamentally different than an otherwise healthy person who is being diagnosed with AFib through a screening device.

This group needs to studied rigorously, and Apple is working on that. They just launched their first important study, the Heartline study, which is focused on older adults wearing Apple watches and what to do with those who are diagnosed with AFib.

But our best guess of what to do with the younger population is to take the arrhythmia or the AFib that is diagnosed by the Apple Watch and use it to focus on modifiable risk factor controls. Make sure blood pressure stays controlled, make sure cholesterol stays controlled, make sure these patients are exercising and eating well so they don’t develop diabetes. In that sense, use AFib more or less like a elevated risk factor that gives us indication of a higher risk of cardiovascular events or heart disease, but one that we can work hard on reducing if we can control everything else that’s modifiable.

Health apps often fail to change user behavior and are abandoned quickly once the novelty wears off. Do you have an advantage in having self-selected people with cardiology concerns, or do you need to use psychology to keep them interested?

I am a huge skeptic of behavior change apps. I think they have proven time and time again that they can work for very short periods of time, but have no sustained, long-term results.

My hypothesis, and where Heartbeat stands in this challenging landscape, is that it is important to establish a care environment. In particular, a patient-doctor relationship, in which an expert in the field with clinical experience can discuss one-on-one with a patient – face-to-face in our case — what your specific risk factors are, what they mean, why they affect the heart, and based on thousands of patients before you, what happens if left uncontrolled.

The tele-visit sets the stage for downstream adherence, engagement, and going to follow-up appointments and diagnostics. It’s a relationship-based intervention, not dissimilar to coaching, but we think of it as clinical coaching. Patients are more likely to do something and to follow through into care when the doctor explains the importance or the relevance of this condition rather than just an app popping up and saying that it’s time to stand up, go for a run, and eat well.

How does the model work from an insurance perspective?

By being an enterprise-based business model where the self-insured employer or the payer is sponsoring this as a benefit, we refer to people within that network. The advantage of that is that we can focus on finding providers that are doing high-quality care. For us, that means following evidence based-guidelines. Not using the diagnostics that will net them the most fee-for-service money, but the ones that are appropriate based on conditions and risk factors. In doing so, this is the classic value-based play to the payer. We can improve outcomes at a reduced cost, and therefore by starting with Heartbeat, we can guarantee a value-based process, lower events at lower costs.

Will be be a challenge to accumulate enough outcomes evidence to get employers to have confidence that their cost of offering the service will be offset by benefits?

Wellness interventions are in a rocky territory right now. Most people are getting wise to the fact that they don’t really provide clinical benefit. We take that head on by saying, if you want to provide clinical benefit, go after the people that you can demonstrate clinical outcomes on.

Our first layer is to identify those high-risk patients. This is the hot-spotting concept. It has come under fire a little bit lately because the data is not necessarily bearing out what everyone thought would be the case. But for cardiovascular disease, if you take high-risk people and those with comorbid conditions and elevated cardiovascular risk if not early disease, those are 100% the people who are leaving to the cost centers of these healthcare employers and payers with heart attacks, arrhythmias, heart failures, hypertensive crises, and ED visits for chest pain. These are very predictable numbers. If you can get ahead of it and get these patients early care, we can predictably reduce those episodes. That comes with really tremendous cost savings.

Do you have any final thoughts?

The landscape of digital health is changing. We have landed at a place where wellness and digital solutions are coming under fire. The disease-specific ones are starting to work, mostly in the diabetes prevention space, but we are left with this next era of digital management, which is, what do we do when patients actually get sick and need, quote, “traditional healthcare?”

This is the area that I’m incredibly excited about and that Heartbeat Health is taking on. When patients move from digital-only solutions into the traditional care system as they’re getting sicker, how can we get in there and try to halt the disease progression process, provide some online app-based and virtual touches to early care and early progressive management so that we can prevent these outcomes? This will be the next decade of digital healthcare, using it to manage those patients who need it the most.

HIStalk Interviews Jay Desai, CEO, PatientPing

Jay Desai, MBA is co-founder and CEO of PatientPing of Boston, MA.

Tell me about yourself and the company.

I’m CEO and co-founder of PatientPing. Prior to starting this company, I worked at Medicare at the Innovation Center and helped support many of the value-based care initiatives there – ACOs, bundled payments, and a number of the new payment models.

I started this company in September 2013. PatientPing is a care coordination platform. We have a number of products. Our flagship product, Pings, delivers real-time event notification when patients have admissions, discharges, and transfers at emergency rooms, hospitals, skilled nursing facilities, home health agencies, and a number of other sites of care.

How widely are ADT notifications being used?

It has really matured as an industry and as a problem that is being solved across the country. For several types of organizations, ADT notifications are becoming a critical part of their infrastructure to do their work. Accountable care organizations, in particular, those that serve Medicare and Medicaid patients that have frequent visits to the emergency room or the hospital. On the Medicare side, skilled nursing facilities, home health agencies, and other post-acute care providers. I don’t know if I could say explicitly the majority, but a large number of ACOs are using event notifications to do their care coordination activities.

A lot of the opportunities for medical management, improvement of quality, and cost savings tends to be when patients are repeat visitors to the emergency room. That’s an opportunity to prevent a subsequent ED visit by engaging them in after-hours primary care, urgent care, and things like that. At least informing them that that’s available to them to avoid a future visit.

Then on the post-acute care side, there are opportunities to reduce skilled nursing length of stay and have patients treated in home care as opposed to skilled nursing. Those are cost savings opportunities in lower-acuity settings for patients to get the same amount of recovery or hopefully the same speed to recovery. Those alerts are important to be able to trigger those workflows that drive the care coordination that ultimately drives the outcomes.

That’s on the ACO side. More broadly than that, health plans are using notifications. Primary care groups often are doing it for their transition of care activities. Hospitals are using it for their readmission reduction activities. Bundled payment organizations are using it for some of their initiatives. But I think we’re seeing the most widespread adoption among ACOs.

How has your solution avoided being bogged down in the competitive, technical, and cost issues that have hampered interoperability in general?

The need was apparent to me seven or eight years ago. ACOs that we were supporting were very keen to know when their patients went to different providers. I wouldn’t say that it was widespread, commonly accepted, or appreciated that hospitals didn’t feel that it was competitive information that they were sharing, say, with a competitor hospital that had a value-based care program.

Say you’re a big health system within a region. Your patient goes to your #1 competitor within the region. Then that competitor has patients that come to your hospital. In the early days of trying to build this organization, it wasn’t the easiest conversation to convince both of them to share ADT feeds, even though it is just ADT feeds and it’s a pretty lightweight set of information. That kind of notification is already happening, often between hospitals and primary care providers. But it wasn’t that easy.

It has gotten easier over time, where people say, I’m OK with sharing ADT because I need to receive that information, recognizing that I probably need to give it up if I’m going to receive it. We’ve had this conversation with thousands of hospitals many, many, many times over the years. The industry has evolved to the place where there’s more comfort doing it.

Some groups in many parts of the country still aren’t that excited or comfortable with notifying the community PCP, their competitors’ PCPs, or value-based care organizations that they have one of their patients. But it’s a lot more common and folks are more willing to do it.

You had a limited rollout the last time we spoke three years ago. Now that you have established the network and created trust, will you wrap more services around that same connectivity that you use for Pings?

The business has matured quite a bit. We have ADT feeds from over 1,000 hospitals across the country of a denominator of 4,000 to 5,000. We have about 4,000 to 5,000 post-acute care providers that are providing us their ADTs, skilled nursing and home health. That’s the senders of ADT.

We have close to 1,000 provider organizations receiving electronic notifications. That includes ACOs, health plans, Federally Qualified Health Centers, and post-acute providers that have an interest in knowing when the patients go to those 1,000 hospitals and 4,000 to 5,000 post-acute providers. They represent over 10 million patients. The business has scaled quite a bit. We have encounters that are being tracked by providers across the country, at sites across the country. It’s kind of neat to see the network grow.

We think about the future as this. ADT is a really great data source. Every ADT is an opportunity to help a patient who is having an emergency room visit, is being hospitalized or discharged, or is being transitioned to a skilled nursing facility. Every one of those encounters is an opportunity to wrap around products and services to ensure that the care transition is happening more safely and smoothly.

As an example, a patient shows up in the ER. We may know that they have had several other ED visits, they may have had prior utilization of a skilled nursing facility, they’re currently on VNA, or they have an affiliation with an ACO care program. The care coordinator at the hospital or the emergency room is left with the decision of how to best support that transition of care. We think that with the historical context we have on that patient, some of the knowledge we know about their whereabouts, can support that care manager’s decision on what to do next. That could be supporting a care transition and linking that patient into the care program that is most beneficial to them. That could come through a range of products and services.

We are excited to be able to continue to make sure that every one of those admits and discharges and the subsequent care they receive is high quality and safe.

What are hospitals required to do with notifications under the new CMS rule?

The CMS rule contains a number of provisions. The one that we’re focused on is the conditions of participation for electronic notification. They are requiring all hospitals, psych hospitals, and critical access hospitals that have a certified electronic medical record system to provide notification of admit, discharge, and transfer, at both the emergency room and the inpatient setting, to the patient’s care team. They are very specific in terms of what is considered the patient’s established care team. They are also very specific about the information that must be included in that notification.

One key provision is a six-month implementation timeline. Hospitals need to have a system to provide these notifications by September 9, 2020.

How would they meet the requirements without using PatientPing?

Hospitals will have two categories of notification recipients. One is the patient-identified practitioner. A patient comes to the hospital and says, “My doctor is Dr. Desai.” The hospital has the burden to send the notification to that particular provider. That typically happens through EHR workflows. The EHR will have an active directory where they can look up the email address or other provider contact information and then send the notification through.

That often happens at discharge through the transition of care document, the CCD. There are established workflows to send ADT alerts to the patient’s designated provider. Companies like ours don’t necessarily help with that. EHRs typically do a pretty good job with sending those notifications directly, as identified by the patient.

This rule includes a second category, recipients who have a need to receive the notifications for the purpose of treatment care coordination and quality improvement. They narrow it even further to say entities affiliated with the patient’s primary care practitioner as well as post-acute service providers and suppliers with whom the patient has an established care relationship. Entities affiliated with the patient’s primary care providers will include groups like their primary care practice. Their affiliated accountable care organization that is a function of their primary care relationship. It may include groups like their Federally Qualified Health Centers or the independent physician association that their primary care provider is a part of.

Hospitals will need the capability to deliver notifications to those groups. That is different than just sending a notification to the patient’s designated doctor. It’s more driven by a roster or a panel. If I’m the ACO, I may have a roster of patients and I want to watch the ADT notifications that are being rendered. I then want to do a match between those two and then send a notification.

To do that, a hospital probably will benefit from having essentially a router of those ADTs that can compare the list of patients against those ADT messages that are to be generated. They may need more than one router. They may send their data to their HIE that delivers data locally within their region. They may send their data to a national network like ours that provides notifications outside of their state. Or they may have their router point the data to wherever it needs to go. But there are a number of stakeholders that may be out there in the communities surrounding the hospital that have an interest in knowing when the patient shows up at that hospital, and they have a valid reason to do that.

This will be particularly relevant for some of the larger academic medical centers that are referral sites for many patients across the country. Cleveland Clinic, Mayo Clinic, and Hospital for Special Surgery receive patients from all over the country. There may be providers out there in the community who have an interest in knowing that the patient is presenting at that particular hospital. Service providers can help route that notification through to the various endpoints where it needs to go.

Do you have any final thoughts?

The CMS and ONC operability rules are totally groundbreaking. I’m excited about what they will do for patient care. CMS and ONC had a lot of hard decisions to make, and I’m impressed by their commitment to supporting patient care, care coordination, and quality improvement. Many hospitals have been thinking about this and putting solutions in place.

We think this will create a broader national framework under which this information is going to flow. We’re excited about that. We’re excited to support it and be part of the solution. Obviously we won’t be the only solution. We’re excited to be part of this solution and we think that there’s going to be a lot of good things that happen for patient care as a result.

We’ve been committed to this mission for a very long time. ACOs, provider groups, and health systems are doing a lot of really hard work to try to support patient care. Data is often at the center of that strategy, or is at least part of the strategy. Being able to facilitate these care transitions with more real-time data sharing across all the different places that patients might go will do a lot to support care. I’m excited to be part of the solution and the momentum that will come with it.

HIStalk Interviews Eric Jordahl and Anu Singh, Managing Directors, Kaufman Hall

Eric Jordahl and Anu Singh are managing directors over treasury and capital markets and mergers, acquisitions, and partnerships, respectively, at Kaufman Hall of Chicago, IL. 

What are the most significant challenges hospitals will see as a result of the coronavirus pandemic and the resulting economic turmoil?

Anu

The problem is the time it takes away from more strategic and more management related tasks. The biggest challenge that executives are going to face is that the time, resources, and attention needed to deal with this will take them away from many other tasks. Prioritization of what is now strategic and what is most critical is going to have to get reshuffled. Time is a precious resource and we’re going to see it constrained even further.

Eric

I would agree with that. I focus on the treasury side of things, where it’s really all  about volatility. When you get into moments like this with a lot of volatility, it’s difficult to make solid decisions. Decision-making becomes an incredible challenge because it’s difficult to understand where markets are going, what good pricing looks like, and what good execution look like. Whether it’s the asset side of a balance sheet and the investments that hospital CFOs are worrying about, or the debt side that they’re worried about, volatility creates all sorts of challenges on either side of that balance sheet and makes decisions about what to do in the moment very, very difficult.

What will be the health system margin and cash flow impact of treating large numbers of patients?

Eric

There was a phenomenon in 2008 called deflating balance sheets. As the value of equity instruments went down on balance sheets and different things happened, client balance sheets got really strained. What was interesting, though, was that was across the whole universe of providers, especially with regard to credit positions, they weren’t really impacted by that event. Where things got dicey was when that whole-industry phenomenon was paired with weaker operating performance at a particular facility. That’s where organizations in 2008 had credit and rating kinds of problems. I think it will be similar in the world today, where a lot of the industry will be hit in similar ways.

The question is, will there be some pockets, areas of the country, facilities, or different things where the impact is disproportionate for whatever set of reasons? If 2008 was any kind of indicator, it’s those kinds of more isolated pockets that are going to be more problematic.

Provider credit and  uncompensated care will be a very big problem, and I think it escalates across the whole US economy. Conferences and sporting events are being cancelled. You see an economy that in some ways feels like people are saying, “Let’s just stop the economy.” The ripple consequence across everything, including healthcare providers, is going to be a challenge.

We’ll see what happens with payers and how their performance holds up. Obviously the government is heavily involved in payment around healthcare. I would expect, given that this was a healthcare crisis, that the government would be pretty actively involved in trying to create financial safety nets of some sort. But I don’t think anybody has a real clear idea right now of what that might mean.

How will non-core health system activities, such as mergers and acquisitions, proceed in the near term?

Anu

Anything that was a strategic initiative — M&A, innovation or a venture fund, acquisition of a physician practices or real estate, whatever the case may be — will continue.  When you have a good strategic rationale to do something in a way that is  battle tested, even an event like this that is upon us doesn’t necessarily change the strategy. What could change is the timing and the pace of those pursuits. It may take longer to complete those transactions.

Acquisitions that require third-party sources — a set of stakeholders selling a physician practice or a source of financing to help with an acquisition – will be more adversely impacted by this event, and you are looking at extended timelines. Some M&A processes may either slow down or follow a different pace. But like most things that come upon us without much warning and without much precedent or even a playbook of how to deal with this, it just slows some decisions down and adds an additional level of consideration. But if it passes strategic muster, it will probably continue.

What would be the early warning signs in a health system’s financials that current events might be causing problems?

Eric

From a treasury standpoint, going back to this thing about balance sheet deflation, a phrase that organizations sometimes use is “fortress balance sheet.” That is a is a balance sheet that is built to withstand shocks. Use of that concept is increasing. Most healthcare organizations raise external capital through external debt markets, where interest rates are falling and have fallen fairly dramatically. On the one hand, organizations think, “Oh this is great.” But on the other hand, other parts of their balance sheet  are affected by financial market dislocation.

It is really understanding your total exposure and how you are positioned to manage those exposures. A lot of CFOs learned great lessons from the 2007-2008 credit crisis, and most of them are coming into this with stronger balance sheets. But that’s still a question that will emerge. One of the main questions is, how long does this last? Does it have a long tail and we get hit with waves of financial market shocks? The longer we go into this, the harder it is going to be for healthcare balance sheets to hold up. That is something that all CFOs should be looking at.

HIStalk Interviews Diana Nole, CEO, Wolters Kluwer Health

Diana Nole, MBA is CEO of Wolters Kluwer Health.

Tell me about yourself and the company.

I’ve been at Wolters Kluwer for five years, and in and around healthcare since 2006, starting in the radiology area. Wolters Kluwer focuses on the education of medical practitioners, nurses, and pharmacists and helping them with clinical decision support tools and ongoing educational tools. The business itself is a little over $1 billion and has around 3,000 employees. We employ a lot of clinical people, which is a rarity among vendors. We couple technology and clinical expertise.

What progress has been made in turning research findings into frontline provider decision support?

We are heavily focused on that area. People search journals for a tremendous number of use cases. One of our core clinical decision support tools, UpToDate, was created from the discovery that you can’t just have somebody looking through all the journals, yet you need this information updated and you need it in the actual practice of decision-making and the clinical workflow. Even within UpToDate, we still serve up the information based on what the clinician is asking for, kind of the “Google for doctors,” but deeply curated and precise.

A customer told me they love the product, but don’t want to completely rely on the doctor knowing what to look for. More and more we are integrating the information with the EHR systems to support the patient context. We can serve up the most relevant topics for the topics for that particular patient. That’s why we introduced UpToDate Pathways. 

On the journal’s content, we continue to look for things that would be easier to absorb. We’ve applied artificial intelligence to pharmacovigilance for the life sciences industry, where we can sort the information that they’re looking for so that information that is more relevant and might need to be addressed sooner appears right at the top.

We continue to talk with customers about what they do with the information after they get it. What other systems do they need to have it integrated in? What’s the workflow? That will be more and more of our focus — deeply integrating it into the practical workflow. There’s an overwhelming amount of information for those who are practicing.

What’s involved with tailoring the information to the patient level?

You rely on interoperability with the EHR systems. We always have it resident within — you can launch it from the EHR — but more and more we’re trying to have relevant information from the patient record passed into UpToDate, which can then augment a search, but it can also tell you that clinical pathways exist for this particular context of this patient.

Let’s say they have AFib and you need to figure out the best treatment pathway, with particulars about this patient. What other kinds of things are you dealing with in terms of this patient? That helps get the evidence and the information that you want to look at down to a smaller, personalized set.

How do you see artificial intelligence affecting your business and healthcare in general?

It’s a big topic. I’m smiling because of my computer science background, where I always think technology should make something more useful. We are applying it, like many other vendors, and trying to be pragmatic. We’ve all seen these big taglines where the robot will see you versus the doctor. We don’t think that’s going to be be the immediate use of AI. We’re focusing on how to reduce variability in care. 

We even start way back at education. How is the person educated? It’s not in a lecture hall any more. Now we have tools that use AI and do adaptive testing, so the student can self-test their knowledge. You can’t game the system – it asks the student in many different ways how they would answer certain things. That has been proven to get a much deeper level of education and clinical judgment, to  get them ready to get out there.

Other specific use cases involve strong evidence, where you just need the information quicker. We are applying AI to areas like sepsis detection, C. diff, another hospital-acquired infection. AI that can constantly learn the pattern that indicates that a patient may be experiencing it can make the information available sooner. It can be better than a human at continually checking those things.

In my prior world of radiology, AI will be applied to some promising areas involving the images themselves that will help the radiologist. We’re seeing a good impact and tangible improvements.

How much of clinical practice can be directly supported by available evidence? Do you have to consider in product design that recommendations aren’t as black and white to the clinician as they are to the computer?

Everybody wants to help a patient get better. The patient themselves always wants to get better. But so many breakdowns exist within the system, so that even if the doctor follows the evidence guidelines, will the rest of the care team play out and will the patient follow it? It was surprising to me so see on a recent survey just how often that doesn’t happen.

Why somebody might choose to not follow the evidence is probably a deep psychological issue. In addition to having toolsets, not everything is black and white. Clinicians build their knowledge base through other assets, such as talking with their fellow clinicians. There’s also complexity, and sometimes in the most complex cases, I have to make a decision, see the result, and then take another fork in the decision-making and see what that is.

Where we focus is to your earlier point. For certain practices where there is extremely strong evidence, there shouldn’t be any reason to not follow it. That is being more and more adopted. People ask, if we move from from fee-for-service to value-based care, will that push it even further? I think maybe it does, but in general, everybody is trying to get access to the evidence in the best way possible way and to follow it, but there are definitely places where that can fall down.

What is coronavirus teaching about using technology to address a quickly changing and widespread medical situation?

People have compared and contrasted it with SARS and other things in the past. Getting constant news and updates is creating a lot of uncertainty. What should I be thinking? What should I be doing? We and other vendors are trying to help by putting the best evidence and information out there so we can get people focused on the facts at hand and how to treat it best. 

People are being prudent at the settings they put themselves in. They are saying, why put ourselves at risk for further issues by having conferences, meetings, or heavy travel? People are starting to be much wiser about that.

What is different now than in the past is this constant update of information and the lack of true facts on what situations you should avoid. They are in contrast with one another. We need to focus on the facts at hand, what people really know about the situation.

How are providers and life sciences companies using technology to work together on research?

Our Health Language product, which normalizes data, is being used in a life sciences setting for post-clinical trials, where a drug is out in treatment. They are getting data from patients who are using the drug in real time from EHR and other systems. They normalize it to potentially adjust the treatment pathway for this specific patient, and then more quickly understand through their own research whether things need to be modified.

It was impressive to me to learn how this normalization tool can be used in such a great way. In the past it, it probably fell apart a bit — how you get the data out, make sense of it, and do that across so many disparate systems. At least nowadays, everybody really is in a digital record of some type. That’s on the back end for the treatment purposes, but obviously you can see where people could get access to data and then try to work on things across systems of data. That will hopefully help solve problems like coronavirus and others more quickly.

Do you have any final thoughts?

I really am glad that I made the move into healthcare from a vendor perspective in 2006. I continue to be so impressed with the people who I get to work with and the customers I get to interface with. There are big problems out there, but I see tremendous tenacity and passion for trying to solve them.

HIStalk Interviews David Fast, President, Agfa HealthCare North America

David Fast is regional president, North America and VP/CFO/COO of Agfa HealthCare of Morsel, Belgium.

Tell me about yourself and the company.

I joined Agfa HealthCare 11 years ago as the North American CFO. After a couple of years, my role was expanded to cover the CFO role for our Latin American business. I spent a couple of years supporting them, then refined it back to North America and added the COO title to the North American operations. For a few years, I was doing CFO/COO for Agfa HealthCare IT in North America. Just over 12 months ago, I assumed the role of president of the North American region.

How much of the company’s focus involves imaging?

Our customer base is still very much radiology imaging, but customers have been asking us to expand our expertise to help manage all imaging across the enterprise. There are actually over 70 service lines in a typical health network that produce medically required images. Managing all that imaging data is a huge and costly undertaking for CIOs and their IT departments. Our new enterprise imaging platform is designed to reduce complexity throughout all image producing service lines or “ologies” if you will. Our goal is to provide the complete patient imaging record in a health system’s EHR, whether the images come from radiology, cardiology, point of care imaging such as ultrasound, surgery, or wherever medical imaging contributes to the care plan.

Consensus seems to be that artificial intelligence will support rather than replace the clinicians who interpret images. Will the workflow component be the key element?

I would say so. We prefer to use the term augmented intelligence, as our focus is to assist clinicians in making informed decisions, not to replace them.

And, you are absolutely correct: Workflow will be key since the technology will only be useful if it becomes part of the clinician’s routine. We have people focused on augmented intelligence, most recently in the mammography area, where our customers have found that the technology can assist and aid the clinicians in making better decisions earlier on in analysis of these images, which can be complex to read. We think it will augment rather than replace the kind of care they can give.

What level of integration exists between imaging and imaging workflows and the EHR?

The whole industry is evolving for sure and this has been a key focus area for Agfa. We find our enterprise imaging solution must be connected to the EHR in each subspecialty are in order to maximize the benefit for the clinician and ultimately the patient. Our technical teams routinely work with the major EHR vendors on integrations that either we or healthcare providers ask for.

How will patients carrying their own images on CDs from one provider to another be replaced with more sophisticated imaging interoperability?

We have a solution today called Engage Suite that addresses just that issue. It is quite typical, unfortunately, for a patient to get a CD from a small imaging clinic and then have to run across town or across state to bring that image to another viewing physician in order to receive timely care.

Engage Suite is an interface with our enterprise imaging platform that facilities connections to various venues, such as remote clinics or big hospital groups. They can exchange images, view, archive, and move them around electronically. There’s no more need for CD burning and running the CD across town. We see the ubiquitous sharing of medical images as a differentiator.

Do use cases exist for using imaging and related information in population health?

I would say so. For the most part, we still see imaging in a traditional sense of being imaged by professional technicians in order to advise a diagnosis. But more and more you’re seeing that both physicians and patients, as with people in general, are using their cell phones to take pictures and send them in. That will broaden the horizon of how we address patient care. It’s at the early stage but will evolve. We call these medical selfies and they can contribute to an increase in patient engagement and satisfaction in their care.

What do radiologists see as their most pressing challenges and their greatest opportunity?

There’s a lot of consolidation going on in the industry. From that perspective, institutions are looking for the ability to have systems that can not only be enterprise-wide from a facility perspective, but that are also scalable and sustainable when it comes to their acquisitions. From the radiologist’s s perspective, they want to be able to retrieve images quickly from wherever they came from and have the best view of that image on their screens as quickly as possible.

We have a good solution in terms of our universal viewers and the whole workflow piece that you mentioned earlier. That is critical when it comes to the radiologist being more efficient. Getting more done more quickly and more accurately is the name of the game in healthcare today.

Are radiologists prone to burnout from the time and accuracy pressures? How do the technologies they use impact their stress levels?

It’s dependent on the individual, but the focus of radiologists is productivity. They define their success in being able to read images quickly, but also effectively, so that they’re giving patients the best care possible. But at the same time, it’s disheartening for them when their systems create delays.

The key for our environment is that we make them more efficient, not less efficient. That means having a system that is responsive and very quick, with viewing and reporting capability. They are constantly demanding systems that will make them more effective and more efficient and our job is to help them do that.

What will be the most impactful changes in the next five to 10 years?

We had the vision of this enterprise-wide solution a few years back. We were primarily a radiology PACS company, so we were primarily supporting the radiology department. We had a cardiology solution as well, but now that we have this enterprise-wide solution, we’re just scratching the surface. It’s mind-blowing to think of how much we could get done in adding other service lines and anything related to imaging that happens in a healthcare system and what that would do for patient care.

Radiology and cardiology are probably still the biggest imaging departments that are touched in one system. But as we go forward over the next two or three years, forget about five to 10 years, the whole platform of enterprise-wide imaging solutions is going to take off dramatically. You’re going to see a very different world not too long from now, less than five years away.

Do you have any final thoughts?

We have a fantastic opportunity and a good future in front of us to truly contribute to reducing total cost of ownership of imaging systems and reducing complexity in health IT. Our solution and the technology that we have developed is getting to maturity. We are doing a lot of terrific work in our labs and development centers on value-adds to that platform. I see a huge potential, particularly here in North America, the area that I oversee. Agfa HealthCare is a Belgian company, but we have very much turned our focus on the North American market, and with that will come additional investment that will drive the results and our market share here in North America.

HIStalk Interviews Adam Wright, PhD, Director, Vanderbilt Clinical Informatics Center

Adam Wright, PhD is professor of biomedical informatics and director of the Vanderbilt Clinical Informatics Center at Vanderbilt University Medical Center in Nashville, TN.

Tell me about yourself and your new job.

I’m a professor of biomedical informatics at Vanderbilt University Medical Center. I also direct the Vanderbilt Clinical Informatics Center, or VCLIC. As a professor, the main part of my job is research. I get grants, write papers, and teach. I teach a lot of the students in our biomedical informatics and medical school courses. Then I also do some service. I help direct the decision support activities here at Vanderbilt, trying to make sure that we have good alerts and other decision support tools and that we’re not unnecessarily burdening our users.

What are the best practices in getting clinician feedback when developing and monitoring CDS alerts?

You need to involve clinicians when you are developing any alert that will affect them. There’s this tendency for orthopedic surgery to say, “We should ask anesthesia to respond to this alert. We should really tell those guys what to do.” That’s almost never the right answer. It almost always works better when users are involved in the development of an alert.

I’m also a huge fan of using data. We have enough data in our data warehouse to forecast ahead of time when an alert will fire, who it will fire to, and which patients it will fire on. Looking at the data is often really illuminating. We’ve just been dealing with some alerts here at Vanderbilt that were firing in the operating room and suggesting giving a flu shot to a patient who’s in the middle of surgery. That’s just not a timely moment to give a flu shot.

You can figure that out after it’s live, but you are better off looking at some data and guessing what’s going to happen. Then making sure that you’ve added all the proper exclusions and tailoring to make sure that it’s firing for only the right people. That’s the most important thing in building the alert and designing it to not frustrate people.

Once it’s live, you need to, on almost on a daily basis, look at your alerts and see how often they are firing, who they are firing for, and trying to figure out if some users are particularly likely to accept an alert or particularly unlikely to accept an alert. There’s this classic problem where alerts fire for patients who might be on comfort measures only. That may not be appropriate for a lot of alerts. Or there’s a particular user type, like a medical assistant, who may not be empowered to act on an alert, but is receiving it anyway. We have found that by looking at the data, we can add additional restrictions and exclusions to the logic until we get the alerts to the right person at the right time.

We have a goal of between 30% and 50% acceptance for our alerts. We don’t always get there, but we see in the literature a lot of places that are at 1% or 2% acceptance for alerts. That is almost certainly a problem, because then people get fatigued and start tuning the alerts out.

Are hospitals comfortable including a “did you find this alert useful” feedback mechanism, knowing that they are then obligated to take action accordingly? Or to allow clinicians who don’t find an alert useful, such as a nephrologist who is annoyed at drug-renal function warnings, to turn them off?

We have a policy here that we are trying to build feedback buttons into all of the alerts. When you see an alert, there’s a little set of smiley faces in the corner. You can vote whether you like the alert a lot, not too much, or not at all. You can click to vote and you can type in a comment. I try to respond to all of those quickly and try to understand the person’s thinking, their rationale.

We were worried that people would use the feedback comments to to grumble about alerts or how they don’t like the EHR. In fact, people tend to give thoughtful comments about why the alert didn’t apply to a patient or it didn’t fit well in their workflow.

We got another one about a week ago about influenza vaccinations. Some clinics don’t stock the flu shot. They don’t have it in their refrigerator, so they can’t give it. We had some conversations with our leadership about whether we should start stocking and administering the flu shots in those clinics, but decided that wasn’t going to be practical. We were able to then edit the alert so that it doesn’t fire for those people.

I agree that some alerts that might make sense for a primary care doctor or hospitals that wouldn’t necessarily make sense for a specialist who really knows that area. It’s futile to show an alert to somebody who says they don’t want it and our data suggests that they are unlikely to accept it. We have to  target our alerts to people who are likely to be willing to accept them.

It’s almost a false sense of security. If we are really worried about renal dosing for medicines and we know that we have an alert that doesn’t work, we shouldn’t just congratulate ourselves for having a renal dosing alert. We should consider more carefully what workflows we have and what additional protections we could put in place to make sure that patients with impaired renal function get the proper medicines rather than congratulating ourselves for having an alert that we know doesn’t do anything.

Default ordering values are important, as emphasized again in a recent study that demonstrated reduced opioid use when default prescribing quantities were lowered. Do you account for this by assuming that physicians aren’t paying attention and will most often accept whatever comes up by default, or is more complex psychology involved?

We had an admission order set that had cardiac telemetry checked by default. We saw that people were ordering telemetry on almost all of the internal medicine patients when they used that order set. We were getting feedback that in many cases, it wasn’t appropriate. As an experiment, we kept it in the order set, but switched it from being checked by default to being unchecked by default. We saw a huge reduction in the number of patients who were ordered cardiac telemetry.

We worried about the risk of that. We did some analysis to see if patients were either having more bad cardiac events or even just if people were then ordering cardiac telemetry the next day or later in the visit, like they somehow missed it in the admission. What we saw was that there was no increase in cardiac problems. There was no pattern where people were ordering delayed telemetry.

You have to be thoughtful about this. You have to get clinical feedback from users. You have to understand what the risks are. I am a huge fan of measurement. We made this change and we measured it the next day. If we had seen that there was a problem, we would have felt confident that we could quickly roll the change back and analyze it. We felt safer knowing that we would be able to monitor it.

In terms of the psychology, some of it is just being on autopilot. You’re admitting a lot of patients, and the computer in some ways seems to almost speak for the institution. The computer is telling you, “We generally recommend that you order cardiac telemetry for patients like this.” That may not be what the builder of that order set intended when they checked it off, but that’s the message that is getting communicated to the intern or PA. They’re likely to trust that that’s the standard of care, that’s the practice here. I’ve seen that again and again. People are willing to trust defaults.

I don’t think it’s laziness. I don’t think it’s that they don’t read it. A lot of things in medicine are soft calls. You might just want to do what people usually do. Seeing something checked or not checked in an order set is an easy way to think that you’re getting a read of the organization’s standard practice.

Your two most recent jobs have been with huge health systems that were among the last to switch from a homegrown EHR to a commercial product in Epic, and both institutions were known for programming their self-developed systems to give clinicians extensive, documented guidance for making decisions upfront rather than punishing them with warnings when they did something wrong. Does Epic give you enough configuration capability provide similar order guidance capability?

Both organizations had for decades developed and used their own electronic health record and CPOE system and then switched to Epic in the last few years. I had a lot of anxiety about that switch. We were used to having the total control that comes with having developed your own software. We could literally pull up the source code of the order entry screen and change it to do whatever we wanted.

I would say that I’ve been pleasantly surprised by the number of levers we have and customizations that we have available to us in Epic. They have thought through most of the common use cases and built some hooks so that we can even go so far as to write custom MUMPS code that changes the way things work.

We have generally been able to find ways to implement things. They might happen at a slightly different point in the workflow or they might look a little bit different than the user expected, but I would say that it’s rare that we come up with a piece of clinical logic that we are not able to faithfully implement in Epic. I was pleasantly surprised. I was actually quite nervous about this and it went better than I thought it was going to.

How do you approach EHR configuration knowing that changes may take more clinician time or increase their level of burnout?

The EHR gets a lot of blame for burnout, and some intrinsic properties of the EHR contribute to burnout. But I also think there’s a lot of regulatory, quality, and safety programs that are implemented through the EHR. The EHR gets blamed for having to enter all this information or to sign the order in a certain way, but some of that is triggered by external forces, like how we get paid for healthcare or how we report quality.

I generally don’t like it when I am asked to implement decision support purely for an external reason, such as because some regulator or somebody else wants us to do it. I would rather partner with clinicians who are likely to have to actually do the work, asking them if are there alternative workflows that we didn’t think of that could achieve the same regulatory goal and meet our obligation to our payers and regulators without  burdening people with point-of-care, interruptive pop-up alerts.

As we  move toward value-based payment, where we’re paid to take care of a patient over the course of a year, we have more opportunities to use things like registries and dashboards. We can have a care manager or a navigator do some of the work, or send some messaging directly to the patient, instead of popping up a message at the beginning of the primary care doctor visit and forcing them to answer a question right then.

One of the things that I’ve tried to do everywhere I’ve worked is to look at requests such as, “Please build a new interruptive pop-up that affects user X.” We go one step backwards and say, what’s going on that makes you think we need to do that? Have we considered all the options before we do this last-ditch effort of interrupting somebody in the middle of their visit?

What are the most pressing informatics priorities at Vanderbilt?

Physician burnout is certainly one of them. We are hearing increasingly from our users that they are spending a lot of time outside the clinic writing notes and finishing their documentation. We are also adapting the EHR to new care models, like value-based payment and telemedicine. We’ve been working on some new approaches for patients to get care either at home or at satellite sites that are not right here in downtown Nashville that might be more convenient to them. There’s been a lot of work trying to get the EHR to do that.

I also have a big interest in academic informatics. Eighty percent of my job is working as a professor. We started this new VCLIC, the Vanderbilt Clinical Informatics Center. One of the goals of that is to help us navigate this transition from a self-built EHR to Epic. There’s a lot of things that we used to know how to do. How do we get data out of our system? If we have a new idea for a medication prescribing workflow, how can we pilot it in the EHR? Some of that knowledge went away when we made the transition to Epic.

The goal of VCLIC is to make people at Vanderbilt say, it’s easy to interface with EStar, which is what we call Epic here. Whether that means getting data out of the system or putting a new intervention in the system. I want people in the informatics department, in clinical departments, or the pharmacy to be able to know how to get the data and know how to do stuff.

We call it paving the road. Getting access to the data warehouse might be based on bumping into the right person or getting a favor. We want to figure out, what are the requirements to get access? What training do you need to have? What do you need to do or sign to acknowledge the privacy issues? How do you protect the data? Then make it clear to people how they can interact with this new commercial EHR in the ways that they were used to in interacting with our self-developed EHR for the last couple of decades.

Do you have any final thoughts?

This is an exciting time in the field of informatics. We got through this hump of adoption of EHRs. Most doctors and most hospitals are using EHRs. There’s a growing sense that we are not getting everything we expected or hoped out of that investment.

The good news is that achieving adoption was one of the hardest parts. Now we need to be thoughtful about using data, engaging with users, getting feedback, and making smart decisions about how we can improve the EHR so that we get the value out of it in terms of improved patient outcomes and reduced costs that we were hoping would appear.

Some people are in a moment of despair about EHRs. I’m actually in a moment of real excitement. We have everything lined up to be able to give value. We just need to be smarter about how we do that.

HIStalk Interviews Dennis McLaughlin, VP, Information Builders

Dennis McLaughlin is VP of the Omni product division (Omni-HealthData) of Information Builders of New York, NY.  

Tell me about yourself and the company.

I have been with Information Builders for quite some time, specializing in data and data integration technologies. I have been involved with the healthcare business since we started investing in it roughly 10 years ago. It has become a significant, strategic part of the business. My role is driving the innovation and the technology direction of our healthcare business to match what the market needs and what our customers are looking for.

What are the most pressing analytics needs of health systems?

The biggest challenge that we run into is around data. There’s lots of great movement in the analytics and visualization space, but in healthcare specifically, having a great tool doesn’t do much if you can’t get the data together and work with it in a dynamic and consistent way.

The pressure that we see a lot for organizations is, “I want to do better care management, but I can’t get the pieces and parts of the data in place effectively to be able to do that.” That’s where we’ve been trying to break down some barriers to make it easy for folks to have access to data, have that data be consistent and comprehensive, and to then be able to apply it to their analytics challenges.

How are health systems that are expanding by acquisition making sense of all of the data that starts rolling in from those new organizations and the systems they use?

Healthcare is awesome and gets me excited when I talk about data, because there’s lots of data out there. It’s not that there’s anything wrong with the data that we have, it’s that the systems that run healthcare generally automate healthcare itself. They deal with people or they deal with financials.

When you’re trying to bring the data together and apply it to a set of requirements that weren’t anticipated when the data was collected — for example, almost anything coming out of care management or population health — you need to be able to take that data, apply some level of governance to it, and then be able to answer the questions that the modern healthcare industry is driving forward.

When we started in this business, fee-for-service was the thing. Now everybody’s working under contracts, whether those contracts are guided by CMS or whether they’re guided by the payer. Trying to look holistically at the patient and be able to provide care in a way that makes sense for the patient’s overall benefit and with reduced risk. All of that is driven by data. If the data that we are trying to base those decisions on isn’t good, then the care can’t be good. We don’t know whether or not that patient has had the appropriate level of care, especially in acute care situations and chronic situations. We don’t know what’s happening. The more data we can bring in, make relevant, and make available at the point of care, the more we can bend the curve.

The other side of this is that traditionally a lot of systems, like EMRs, are right there at the point of care, but some of the advanced data and analytics that you are going after don’t really get analyzed until down the road. It’s hard to make an impact for a patient who’s sitting in front of a doctor.

Another of the trends that we are seeing is, how can we take this insight that we’re developing out of the data, start to bring it to a much more real-time perspective, and get that information right there to the point of care?

Are health systems making bad operational decisions or failing to make operational decisions because their data governance is immature?

It would be unfair to be judgmental to folks on decisions that they made, mainly because in many cases in healthcare, unlike almost any other industry, the business of healthcare tends to drive decisions about the technology. The poor IT department is constantly on the ropes reacting to, decisions such as, “We’re going to have a new EMR. We’re going to have a new system to manage these cancer drugs. We’re going to have a new system to manage cost.”

A lot of our IT partners are responding constantly in a reactive way instead of a proactive way. Despite their efforts, even those who are dedicated to data governance recognize that if the chief medical officer makes a strategic decision about a particular automation system, that thing is probably going to happen. What we have to do after the fact is to figure out how to then govern the data that is flowing through that system and the way it interacts with other systems.

It feels at times like our customers are in a constant scramble to balance the needs of the business, while at the same time recognizing — especially those on the data and IT side — that they have a responsibility to ensure that data is of the highest quality. Especially for the organizations where they’re dedicated to making data be a strategic asset in the way that they approach the business, whether that’s related to quality, care management, or any of their initiatives.

A lot of the initiatives of these health systems relate to being the highest-quality provider in the area, or branching out to cover the largest potential population. That takes us back to, do we have data that can support that agenda?

Are health systems using more external data, such as from claims or pharmacies?

Absolutely. The health systems and organizations that we deal with have a voracious appetite for data. They want everything that they can get. They would like to get data from the payers. They would like to get data from labs that aren’t their own labs. They would like to get data everywhere they can.

Probably the number one question we get involves data related to things like benchmarking or feedback loops. A lot of the folks in healthcare have a scientific background. They are paying close attention to what the market is doing, what particular studies are in play, determining the best way to run their business, and figuring out how to best interact with their patients. In those cases, outside data is critical for being able to do that.

The challenge that they have is that in healthcare, while there are interesting sharing points related to data, I’ve always said, “You’ve seen one HL7 implementation, you’ve seen 40.” While healthcare is moving in a direction of being able to share data more effectively, it’s not the easiest thing for these organizations to do. That’s an area where we try and help them alleviate the pain of that challenge.

Are those health systems working toward reaching out to patients and their communities in general in treating them as customers?

Yes. We have worked with some organizations that have been very progressive in that area. From the ability to recognize when people move into town, to paying very close attention to where they site their clinics and their facilities, trying to match the outreach of the organization to the people in the area where they live, and provide services to folks closer to where they live. All of those would be second nature in certain industries.

You look at an organization like McDonald’s. The way it does its siting is high science. This is coming to healthcare. These folks are recognizing that to be able to effectively manage their customers, their patients, and their families, they have to borrow from some of these other industries. You’re starting to see a lot more of the techniques that we typically might see in marketing, advertising, or retail being applied to the healthcare challenge.

I think it’s a great thing. If I know that a particular group of my patient population has a propensity towards needing cardiac care and I don’t have a clinic anywhere nearby, then I’m not servicing them well. Being able to analyze the patient population, being able to analyze the surrounding market and my competitors, and then taking action accordingly gives an organization a leg up in a market that has become pretty competitive.

Are health systems using technology to help them align with independent physicians, or to co-market their services with their technologies, such as being listed in the health system’s physician directory or taking appointments online?

Yes. Ever since the budget deal that created the requirements around technical automation and doctors, we’ve seen a lot of consolidation in the market related to affiliations. Physicians are joining networks that they never would have considered before or are associating with a network.

At the same time, not everyone is going to hire the physicians into an expanded network. We see organizations we deal with range from, “We are going to expand and market to these physicians and get them to join us” all the way to, “We are going to make their experience so seamless and positive that they will want to affiliate with us, and we can provide a lot of efficiencies that the physician or the physician group wouldn’t be able to provide on their own.”

We did an innovation a couple of years ago that we would not have predicted, and that is around mastering physician practices. It’s not just knowing who the physicians are, but knowing where they’re practicing. Physicians are entering and exiting various practices on a much more frequent basis than ever before. It’s super important for us to be able to feed that information, to be able to say that Dr.  Smith is now associated with this other practice even though he spent 10 years at another place. 

That has been a rapidly changing part of the market, although you would normally think that data and information would be stable. It’s been changing a lot and we have spent a lot of innovation to be able to match it. We make it easier for these organizations to keep track of those folks and to be able to market them when they’re affiliated and not necessarily employed by the health system or the health network through its various tentacles. When we looked at our roadmap 10 years ago, we didn’t look at physician stability as something that would become a significant data challenge, but we have experienced exactly the opposite.

Do you have any final thoughts?

We talked a lot about data, the kinds of things that we’re looking at in the market, and how we are responding. The biggest challenge moving forward for both us and the market is, how do we now use some of the initiatives that are being pushed down by CMS and the market in general — things like FHIR – to take interoperability to a whole new level? One of our key themes for this year is to not only be able to access, manage, and govern this data, but now to look for ways that we can get that data, these analytics, and these insights that derive from the data into the systems that physicians, nurses, and health systems are using to be able to improve care. How to give them additional insight, whether that’s related to social determinants or just pure efficiency. 2020 is the year for better ways of getting data into the hands of the folks that can use it to impact care.