HIStalk Interviews Guillaume Castel, CEO, PerfectServe

Guillaume Castel, MBA is CEO of PerfectServe of Knoxville, TN.

Tell me about yourself and the company.

I worked 14 years in technology, first with IBM and then Cisco Systems. I was fortunate to rise through the ranks. I come from a family of healthcare providers and executives and I am married to a physician-epidemiologist, so I felt I had no choice but to go into healthcare. I joined The Advisory Board Company in Washington, DC in 2014. It was probably the most consequential experience I have had in my career, an amazing 4-5 years before we sold the company to Optum.

Then I went to work for a health system in the DC area. I put what I thought I knew into practice and learned what it means to deliver care every day. I joined the advisory board of PerfectServe about two years ago at the request of our private equity sponsors, and then about a year and a couple of months ago, I became the CEO of the company.

PerfectServe offers unified healthcare communications solutions to help physicians, nurses, and care team members provide patient care. We serve 145,000 physicians, 240,000 nurses, and 600,000 users. I mention those metrics because we track them each month to remind of us the importance of the work that we do and the number of lives that we are privileged to touch each day.

How has the company absorbed its recent acquisitions of Lightning Bolt, CareWire and Telmediq?

PerfectServe acquired three companies in essentially 12 months. Telmediq was complementary to PerfectServe. CareWire was in the slightly different space of patient engagement, which was visionary at the time. Lightning Bolt has become a critical part of our company in delivering scheduling capabilities for physicians, and increasingly, beyond physicians.

We spent a great deal of time thoughtfully integrating the various capabilities and thinking about how we could make the sum of the parts bigger than what they were. What we have now is a cross continuum way of enabling communications at scale for the largest health systems in the United States. We embed optimized and sophisticated dynamic schedules to make sure that we get the right communication to the right person at the right time, which is critical. Then, in this era of ongoing crisis for health systems in the United States and beyond related to COVID, it has become critical to help patients who are inside the four walls of the hospital communicate with their families and for hospitals to communicate with patients who have gone back home.

How has technology changed the ways that hospitals and practices are serving patients compared to a year ago?

We have gone through an acceleration of a three-year roadmap into a three-month timeframe. Care providers suddenly had to manage patient flows safely at volumes that they could not have anticipated. They also had to provide as much care as possible without requiring the patients to come into physical spaces such as a physician office, an ambulatory setting, or an inpatient setting.

The news was most prominent around the advent of telehealth, but telehealth is not new. It has been important in care delivery for years. But we have learned that we can and should provide good care remotely.

PerfectServe has committed to helping our clients through the crisis with bi-directional texting capabilities with their patients and families from home or anywhere they wish to be. We built a video capability, which took off in March, April, and since then because it does not require scheduling – it is completely ad hoc. It is secure and does not require infrastructure for hospitals to deploy it. These are the required ingredients for any solution to become relevant.

Some of our most innovative and forward-leaning clients expected to do 1,000 telehealth visits in 2020, but have already done 300 times that number. Our essentially app-less offering was the most convenient way, in a moment of urgency, for physicians to get in touch with their patients at home or elsewhere.

Do you see a second wave where organizations that quickly implemented consumer tools such as Zoom or Skype will look for video solutions that are more specific to healthcare?

People did what they could during the urgency. Health systems and physician groups are essentially doing pervasive preparedness for what another wave of COVID or another virus outbreak could mean to them. They are thinking about not just what’s required, but what the perfect design would be to stay connected to their patients in a moment of crisis. That goes far beyond having access to video capability.

It needs to be integrated in the way that you would want your physicians, nurses, and care team providers to communicate with the patient. It needs to be safe. It needs to be the right person at the right time. It needs to be secure. It needs to be connected with your EMR. It needs to be connected with the way you would want to manage clinical communications within your hospital.

Horizontal technology providers just aren’t going to get there. They don’t understand the workflows. We are seeing a lot of work and money being spent on how to deal with the next wave or the next crisis. That pushes us and assures that health systems and their patients will be better prepared for the next time.

I saw on your website that 85% of patient records contain their cell phone number, which allows providers to text them with health management questions and appointment reminders with minimal work and infinite scale. I also saw an interesting statistic about how patient portal use can be increased dramatically by texting patients a link to the log-in or to materials that exist within the portal.

It’s fascinating to me what we’ve had to do over the last six months. What you are touching on is critical. We build products at PerfectServe by spending a lot of time with our clients, making sure that we are educated, vetting the solution, and testing it. What we heard about engaging with patients remotely in their use of portals is that it can’t require a three-month deployment. It needs to be lightweight, secure, and app-less. This concept of asking a patient or a patient family member to download yet another application was a non-starter and will continue to be.

We put our best brains on it. We established the most practical things that folks can use in a moment of urgency, and that was essentially a link. We send a link to the phone number that was gathered at the point of registration the week before, the month before, or the year before. That has changed the way practitioners are embracing new technologies.

What are some practical uses of escalating messages that haven’t been responded to within facility-defined parameters?

Our approach to that issue is that we need to enable person-to-person communication, nurse-to-nurse communication, nurse-to-doctor communication, and care team member-to-care team member communication. We also need to track and document that whatever communication was sent has been received and read. The traceability, the ability to audit backward, is critically important to our clients, and we believe that that level of sophistication is now baseline. You don’t get that level of transparency with emails.

We believe that we are differentiated by our standard of delivering the right message to right person at the right time. We do that using algorithms that leverage what we think of as situational variables. The person’s role is the one that is most often mentioned, but it’s much more complicated than that. It also includes their department, the facility, the day, the time, and the call schedule. We establish deep, optimal communication that is based on those variables.

It’s essentially an optimized communication pathway that folks can standardize around. Our most sophisticated clients have established standards across their 10, 20, and sometimes 30 facilities to establish a standard around communications. We track and we give the sender the ability to see who has received the communication, who has opened the communication. It doesn’t need to be sent back that it has been read, but you can track it. We believe, and have always believed, that this is critically important. People are now accepting this is a benchmark and a standard.

Texting, as the preferred messaging mode of many or most people, is a channel by which messages can be scaled infinitely, covering health follow-ups, pre-visit questions, appointment reminders, and anything else that the provider organization feels is important. How do organizations decide how to use that capability optimally without seeming annoying or impersonal to their patients?

Our job is to give our clients options to communicate with their patients in the way they believe is most effective. I don’t believe that voice has completely gone away, so we need to continue to enable that. Texting is core, unquestionably, and video has become important. Six months ago, people communicated maybe 20% by videoconference and the rest of the time with just regular conference calls, but now 90% of my days are spent in front of a camera.

Our goal is to give our clients options for their patients, a multi-channel array of capabilities. The ability to do appointment reminders, surveys, and education pre- and post-visits or procedures is critical. We see it now. I’ve been spending a ton of time with potential partners around this concept of education for patients who are coming in for surgery or an oncology appointment. The more you know, the better prepared you will be and the less stressed you will be, which has proven to have an impact on the efficacy of the care you’re receiving.

We are using all those ways of communicating to funnel real quality to patients, pre and post, having an interaction with a care provider. That’s not going to go away. How people decide to digest it, how proactive health systems are in actually promoting it, is a  matter of sophistication level. We are committed to helping any and all systems, regardless of where they are on that spectrum of sophistication. But I believe that the engagement with patients and consumers will grow through text.

People don’t talk as much about the importance, the crucial importance, of the call center. We see call centers as a core to that multi-channel communication strategy. They are a huge part of how clinical communications are relayed to and from the front lines and patients and family members. There are massive opportunities for health systems to engage more effectively.

People like texting because it can be real time if both parties are available and interested, but it can also be asynchronous if you don’t catch someone at the right moment. Does that same concept apply to video, where two people converse via video messages that aren’t necessarily answered in real time?

I think it’s all based on the use case, the degree of acuity, the stress expressed by the patient, and the urgency expressed by the health system. These are all variables that come into play. We think that having three or more ways of applying communication strategies to the situation is the right answer.

Texting seems most convenient for less-urgent situations, but when you’re back home after a round of chemotherapy, you want immediate video or voice feedback from a care professional who can tell you that how you feel is normal and you don’t need to drive an hour to come back to the facility to be checked out. We will continue to invest in having as many communication strategies as possible to allow every use case to be facilitated by our platform.

Do you have any final thoughts?

The journey is what we think of as unified communications. It crosses boundaries and it cannot be an afterthought. It needs to be core to the mission of the company that commits to delivering it. Similarly, workflow enhancements can be achieved by combining technology and innovation with experience and know-how, not just releasing tools and demanding that a clinician use them.

All 350 of us at PerfectServe wake up in the morning with a desire to solve bigger problems for our clients and their patients.We start with the end in mind. We are excited about the progress that we have made with our clients and the progress that they are making with their patients.

HIStalk Interviews Jose Barreau, MD, CEO, Halo Health

Jose Barreau, MD is chairman and CEO of Halo Health of Cincinnati, OH.

Tell me about yourself and the company.

I’m a physician and oncologist. I practiced until 2015. I was involved in creating a cancer institute and what I called multidisciplinary care, where a patient can come in and see all of their oncology doctors — surgical, medical, and radiation – at the same time. That got me interested in communication and collaboration and how that is important to a health system.

Halo Health offers a clinical collaboration platform. It is a cloud-based application that goes across health systems and has every clinician on it — doctors, nurses, and medical staff. It allows them to message each other, call each other, and receive alerts. It supports real-time clinical communication on one application across the system. We focus on real-time, high-priority, urgent and emergent information and communications.

How would you describe the clinical collaboration platform market and how Halo Health differs from its competitors?

We are focused on role-based communications, which is different in healthcare than in other businesses. About 40 to 50% of healthcare communication with a role you know – such as “cardiologist on call” or “charge nurse on the 14th floor” – rather than a named individual. Our platform allows for accurate manual and schedule-based, role-based communication, which differentiates us from anyone else.

How has the care team definition changed with COVID-19 and the rise of telehealth?

We started off as a secure texting application. We realized pretty quickly that secure texting is OK, but it is poorly adopted. People only text the people they know are working at that moment, so the platform is adopted only in pockets. Identifying roles and communicating call message and alert roles opens up the other 50% of the health system in a single platform.

With COVID, we really needed to set up teams, identify contacts, and get people moved through the system quickly. For example, “COVID charge nurse” is a role that multiple people fill based on the time of day, and a role-based platform can support that.

How has the mix of message types changed between real-time voice and asynchronous text?

I learned two things in studying communication and collaboration. Doctors and nurses want to do things faster, but they also want to be interrupted less. A doctor or nurse is interrupted from a patient encounter every time their phone rings since they are usually in front of a patient. That’s a problem when just calling them or messaging them with routine information. You want to give them a chance to respond when they can, and asynchronous communication is effective for situations where you don’t need to answer right away, but instead can wait a few minutes to wrap up your conversation with the patient. Nurses and doctors want patients to feel like they are the most important thing in the world to them at that time.

Do clients expect their messaging systems to be integrated with other systems?

They do. The big question is, what do you integrate? We are trying to clearly define that to protect the platform. We don’t want all the information that’s out there. If you want something from the EHR, we want you to go to the EHR. We also want to keep integration real time, so we integrate with the nurse call system, the PBX, physiological monitoring, and those types of things.

We have to do discovery about what that organization thinks is important. Even the level of integration with the EHR depends on what the organization wants.

Do you have to protect clinicians from being barraged with messages that non-clinicians send just because it’s convenient for them to do so?

I battled a long time with that when I was practicing medicine and directing the cancer institute. Some physicians are comfortable with being contacted when needed, but others don’t want anyone contacting them. We do a lot with healthcare leadership, such as chief medical officers. I personally feel that physicians should be open to communication from everyone, but everyone should know what is appropriate to communicate at what time, and that’s our philosophy.

I don’t think doctors and nurses should be on separate platforms, although some people believe that. I think that’s a huge mistake. One communication platform for everyone is appropriate, as long as the platform can provide certain protections and users have been educated on what is real time and reminded that they are interrupting a doctor or a nurse.

I find it funny that people talk about interrupting doctors, but nurses get interrupted all the time and nobody is saying much about that. Nurses are barraged with alerts and all this type of stuff. It’s OK to interrupt nurses eight times when they’re with a patient, but it’s not OK to interrupt a doctor. I would argue that nurses often spend more time with patients and develop stronger relationships with them.

It needs to be looked at holistically across the organization in terms of each role, but each doctor, nurse, or other clinician should be easily accessible. That’s our philosophy.

Email is notorious for allowing people to add others to a conversation without turning any of the discussion into actual assignments. Are messaging workflow components available to assign actions and log them as either completed or reassigned?

Everything in a clinical collaboration platform like ours is auditable and traceable. It’s usually individual-to-individual or individual-to-role. Everyone has an ID, and there’s an individual behind that role. Everything that is sent, delivered, and read is tracked. If you send a message to five people on the code team, all of them have the responsibility to read the message and respond to the code. The sender can see who has read it and who hasn’t.

You can put controls in place for resending and escalating, but if the message was directed to you or the role you’re filling, you are responsible. That’s why the role-based platform component is important, and having accuracy on the other side so that someone receives the alert or message.

What capabilities of secure communications systems have changed with the availability of cloud-based systems?

We are 100% Amazon technology. We evaluated a lot of technologies in 2015 and felt Amazon gave us the most scalability, reliability, and security. We signed a business associate agreement with them and developed a good partnership.

The Amazon platform gives our product scalability. We can have a huge organization on the West Coast, a huge organization on the East Coast, and another in the Midwest, and all of them can add users and mobile transactions without affecting response times or delivery times. We can add organizations on the fly and constantly release products and features as software as a service. Health systems, physicians, and nurses should be on the latest, greatest technology in the most current version at all times and cloud technology allows us to do that.

How do you see the company’s future?

We have built all the channels, the alerting, the calling, and the messaging. We have a tremendous amount of data going through our system. A lot of it was never captured before, stuff on pagers or on personal phones. We’re focused on data analytics to create insights around communication patterns and communication workflows to define their impact on patient outcomes.

We want to get the right information to the right person, make it accurate, improve patient throughput, reduce staff burnout, and increase clinician satisfaction. The future is in creating those insights and continuously optimizing workflows to improve patient care. We add features and functionality solely to improve patient care. Then we need to have data to show the chief medical officer, the CFO, and people who are playing for the platform how it adds value to patient care in their health system and how it creates return on investment.

Do you have any final thoughts?

The lack of communication and collaboration is one of the biggest, if not the biggest, causes of patient harm right now. Solving this problem will save more lives than a new medication. It has been fragmented in the past. We should all get behind unifying it and shedding a spotlight on the importance of communication and collaboration to keep making progress.

HIStalk Interviews Jay Deady, CEO, Jvion

Jay Deady is CEO of Jvion of Suwanee, GA.

Tell me about yourself and the company.

I’ve been in health IT for 30 years, having started in 1989 with Cerner. I’ve had a series of opportunities and roles on both the clinical revenue cycle and analytics sides of the business. Mostly focused on providers, but with some exposure to payers along the way and keeping my career focused solely on health IT.

Jvion is an industry-leading prescriptive AI company. Our mission is to drive down preventable harm to patients, both clinical and cost-related harm, however we can. That has been company’s mission since Day One. The co-founders have done a great job bringing the company forward over the last eight or nine years. I was fortunate to have the opportunity to join a few months ago as CEO.

Are health systems interested in how AI and predictive analytics work under the covers, or are they just looking for solutions that can deliver the results they need?

They are definitely looking at some of the details. The reason is that over many years, certain terms in healthcare and healthcare IT tend to get somewhat abused and therefore misunderstood. It was “workflow” and “analytics” back in the day and now everybody seems to be an “AI” company. Health systems, ACOs, and payers want to understand how Jvion is different from some other company that claims to be in the space. They are clearly interested in the outcomes and benefits that current clients are achieving and they want to understand how our approach is different.

Do health systems, and particularly clinicians, struggle to trust AI that functions as a black box with hidden proprietary algorithms?

It’s a balancing act. We have proprietary technology and methods, and other companies might say the same. Under an NDA, we will go to a certain depth to explain how it is that we do what we do. Fortunately, we have a relatively large number of clients that have been using Jvion for a while, so those documented outcomes and references help in those conversations. Details about how we approach the data science and strong peer references help. We also use a model control study versus just a benchmarked pre- and post-analysis. We have a lot of rigor around documenting the outcomes we have helped clients achieve.

Will AI become another example where technology companies try to solve problems they don’t understand because they don’t know healthcare?

There is some of that. There’s another side as well. On one hand, you have AI companies that don’t understand how healthcare works. They don’t understand the triangle between a patient / member, a payer, and a provider and how you add value to each constituent by understanding their alignment. On the other hand, AI draws a lot of different correlations and can provide a lot of different solutions for a company that does healthcare, but understands that healthcare is complex and needs help with a lot of questions. It’s challenging, from a corporate perspective, to narrow the focus so that you can efficiently scale versus answering one question for one client and trying to multiply that.

How important is it when training a model to avoid amplifying existing biases and to resist the urge to overstretch the model’s capabilities?

One of Jvion’s differentiators is that we have 33 million lives with between 2,500 and 4,000 data points within our machine. We don’t take in a large volume of data for one particular client, which will be biased to their capture solely, and then run the analysis only against that. Our scale and our nine-plus years of experience allow us to leverage the underlying clusters across those 33 million to even out any regional or local biases that might come from a single data source or data from a single region.

What information from outside the EHR can help identify patients who could benefit from an intervention?

Beyond EHR data, the machine uses publicly available data from the federal government, such as community vulnerability and social determinants of health. There are various capabilities around lab data and claims data. EHR-specific data makes up less than one-third of the data that we have in the machine.

What do clients most commonly learn when they apply a broader set of analytics capabilities to data that extends beyond their Cerner and Epic systems?

There’s a lot of additional data that isn’t contained within the EHR. Cerner and Epic are clearly trying to go down the path of balancing, however they describe it, between analytics and AI. But there’s additional behavioral data — environmental data, lifestyle data, transportation data, and even weather. These have impact on the health of a population and on the health of an individual in a specific area, but they aren’t within the EHR. That is one way that we significantly differentiate our offering from the nuanced early capabilities of what Cerner and Epic are doing.

Is social determinants of health information useful other than recognizing that an individual has a problem that goes beyond the health system’s ability to fix it?

Our clients aren’t just hospitals. While source data for SDOH does in some cases come from health systems, we gather information from other sources.

We break our market down into three segments. We have health systems on the provider side. We have population health entities on the provider side, where on their own or in conjunction with maybe a payer joint venture. There are ACOs or other initiatives where some level of risk is being taken around the defined population, whether that is the hospital’s employee base if they are really large or expanded into a provider-sponsored health plan. We have more than hospitals as clients and sources of SDOH.

What opportunities have arisen from helping customers address COVID-19?

It certainly was an unexpected impact for the industry, the nation, and for Jvion. I started as a new CEO three days after Georgia locked down, and multiple months into my career at Jvion, I think I’ve met 18 of my colleagues in person. I just went on my first in-person client visit in Georgia two days ago, wearing masks and socially distancing. Otherwise, it has been a virtual engagement, and that has had a big impact on general business operations.

At the solution level, the hospital provider segment has been impacted the most. Their economics have been fairly devastated. They were a 2-3% margin business, generally not for profit. They lost 30-60% of their high-margin business for a period of time. Our average health system client will probably be off 20, 30, or 40% of the financial operating numbers they had expected for the calendar year, and that is massively impactful from the operations side. From the caregiver side, the daily onslaught of delivering care in this COVID world versus a multi-service line clinical care delivery system is very different.

We initiated a COVID map that we pushed out for free. We worked with Microsoft on it. It’s available online. We’ve had 4 to 5 million hits and uses of it, everybody from the Pentagon and the White House Task Force to the CDC and others. We mapped down to the actual block area to show the vulnerability of a particular community, which is more beneficial – particularly for health systems – than looking at government data that’s at a county level. We expose that for our clients as well as anybody that would care to use it. We’ve been happy with the massive use.

For our clients, we took a look at their current patient lists, applying both the COVID map and other data we created and something we do for our normal solutions. We don’t just create a list of folks who might be susceptible to a negative quality event coming up and predict that. We do that, but we also put that in rank order based on the ability to intervene with a suggested intervention that could make a positive trajectory change and improve the potential outcome based on what the current trajectory is. A number of our clients are using that to outreach to those in their capture who might be the most susceptible and vulnerable from a COVID perspective to make sure patients are getting assistance.

We created a triage select solution, which we refer to as a vector. It works both for COVID and for any type of potential respiratory-impacting areas or diseases, such as basic flu, where you may need to make triaging decisions around the right time and appropriateness to ventilate. How do you prioritize that as the patients are presenting? That helps our clients deal with the onslaught of folks coming in.

I’m really proud of the team here at Jvion and appreciative of the feedback that we got from our clients in critical, overwhelming times. We were able to take that input, understand their needs, and bring our resources, assets, and capabilities to assist.

Do you have any final thoughts?

The US health system environment has faced challenges in my 30-year career and in the past, but they were more financially market oriented, where hospitals had reduced access to the bond market during the financial crisis, for example. But I’ve never seen anything that was so impactful to the actual operations of the health system itself. We will move through this at Jvion. 

We are also looking at our prescriptive AI, which historically has been solely clinical in nature, to understand the challenges of our health system clients. In those parts of the country that are post-COVID or in a lesser COVID world, how do they start getting a return to care? One client’s research found that 68% of community patients are reluctant to seek care because of fear of going to a medical facility related to COVID.

That deferment of care is having a major impact on the providers and the services that they can provide to patients. They will have higher acuity and more severe illness and disease state based on the deferment of that care. If they’re a commercially insured patient or member, payers have an influx of money today based on all the deferment of care, but there’s a tsunami coming of that care having to be delivered, and it will be more expensive later than right now.

It’s an interesting alignment period, with patients getting the care they need sooner than later, providers needing those types of patients back into their health system, and payers wanting them to get the care now versus deferring it and it being more expensive later. We’re focused at Jvion on how we can help drive that alignment across those three constituents whose interests are aligned with a single incentive.

HIStalk Interviews Matt Wilson, SVP of Healthcare Strategy, Infor

Matt Wilson is SVP of healthcare strategy for Infor of New York, NY.

Tell me about yourself and the company.

I’m a healthcare IT lifer, with 27 years in the industry. It’s kind of a family business. My father was an HIT executive going back into the 1970s, so I have been in and around this business for my whole life. I am fascinated in the way it has evolved and I enjoy watching its trends. It’s a pleasure having the opportunity to participate.

Infor is a global cloud computing company with deep investments in industry-specific lines, executives, and products, such as Infor Healthcare.

How has adoption of cloud technology in healthcare changed?

Adoption of cloud technology gives us an opportunity to manifest a remote workforce, which we’ve seen through the pandemic, and we will see more of that. Cloud provides the ability to rapidly respond to customer needs with updates that don’t require the same kind of effort as on-site, on-premise solutions. We can engage our customers more consistently and more rapidly, which is an enormous benefit of cloud in addition to the reduced costs of maintenance.

Are you seeing a new urgency for agility in your customers since the pandemic started?

We are. Customers need us to be agile, especially in areas such as supply chain and real-time location services. Our objective has been not to get in our customers’ way, but simply to make ourselves available for what they need. We have found that our greatest opportunity to help has been engaging with something that takes a couple of weeks instead of the months and months that we’re used to with typical implementations.

How do you see the synergy between EHRs and enterprise resource planning systems?

Infor as a company, and I as an individual, are focused on how create a more balanced ecosystem. We have spent years and years, decades in fact, investing in EHRs. I was a beneficiary of that, as I helped build Cerner through the late 1990s and early 2000s. The lack of commensurate investment in ERP has created an imbalance.

We believe we can move the industry by modernizing the technology, driving a set of functionalities that contribute to the core mission of patient outcomes and a better system of health and wellness. You must have world-class systems and functionality across the core pillars of finance, supply chain, and human capital management. The way that we use interoperability and the way we orient ourselves to that core mission is critically important.

What is left to accomplish with ERP?

We need to bring together those investments to orient themselves to a single goal. We have tended to think about upgrades and technology as an ability just to upgrade the tech itself. The future holds orienting towards making one leverage off of the other, creating that ecosystem and integrating some of the billions of dollars we spend each year on management consulting on transformation. That transformation creates change. Tech should be used to sustain change. As you are moving forward with big transformation projects, how can you use your clinical solutions, your revenue solutions, and your business solutions to sustain the efficiencies, cost reductions, and tech advancement? That will be critical as we move forward, and we can play a big role in that.

As EHR and ERP vendors get bigger, does the opportunity still exist for smaller vendors to offer an ecosystem of wrap-around products?

Our Cloverleaf solution is the most widely implemented integration engine. True interoperability creates a wire that connects both traditional and nontraditional data sources and care venues, but should be used to facilitate small tech, where the gating factor for cool, innovative companies to have their products used by big health systems is the IT organization. They don’t have the time and resources to complete the interfaces, or there’s a lack of understanding around anything from security standards to interoperability.

Big platform companies like Infor and the large clinical software vendors should think about how we can facilitate the inclusion of that other cool technology that can help drive value. How can we more easily connect them into that ecosystem for the purpose of creating balance? That should be one of the central themes that we as big platform vendors should be thinking about. I think a lot about that in my role at Infor.

How do you assess the federal government’s interest in interoperability?

The Cures Act has laid down to the letter the requirement to interoperate. Vendors often give lip service to how they’re adhering to that, and some vendors continue to push back. We are seeing an absolute requirement to go do that. We’re looking to facilitate it.

What we need is an attitude change. While it can legitimately be an impediment to competitiveness, what we should be thinking about is how we’re working together to advance an industry right now that is not in the best of shape, an industry that is critical to us as a society. We need to take that signal, act on it, and find ways to include others. We are seeing those signals from life sciences, big lab testing companies, and payers that they need to be a part of that as well. They are developing standards that are oriented towards meeting those federal guidelines and making data liquidity a prime imperative in healthcare.

What was your reaction when you saw that the information that is needed for pandemic-related public health reporting was being sent by fax machines and emailed worksheets?

It’s just such an incredibly inefficient process. There is regulation to begin phasing out fax machines, but we need to move more quickly. That’s an area that we think will evolve quickly, even potentially with stimulus, in the area of supply chain and public health reporting. Those are necessary when something goes wrong, such as a once-in-a-generation pandemic.

The billions and billions that we’ve spent were sufficient in areas such as telehealth, but didn’t get us where we needed to be in terms of a fractured and disrupted supply chain and using antiquated technology to quickly report on outcomes. Interoperability becomes a central theme, and while we have had so many attempts with CHINs, RHIOs, and the rest of the alphabet soup, we still haven’t effectively created a true system-wide capability to normalize data and move that data around for those purposes that you’re describing. That’s critical as we move forward.

Are customers asking for new capabilities or guidance to help them stabilize their supply chains?

We asked clients what they need most. We responded quickly by developing supply chain dashboards for PPE. We are proud of how we were able to participate in a bit of a solution. We think that will be an ongoing need, the requirement to connect disparate supply chains and to develop functionality to find clinically equivalent alternatives when a particular supply, device, or PPE item becomes unavailable. We have to evolve with our use of AI, machine learning, and physically connecting suppliers. We will work closely with our customers as we go forward because it will be critical if we experience something like COVID-19 again.

What product opportunities do you see with AI?

For us, again as a platform company, we have so many opportunities to advance and help. It’s really listening to the market. What we are hearing from caregivers and business operations associates is that supply chain becomes a huge issue. We saw human capital management evolve and the role of chief human resources officer created around the country, and we expect to see more senior executive supply chain personnel taking roles in the strategy of the organization.

We also see a huge need around real-time location services in contact tracing, to be able to efficiently understand where a diagnosed patient has been, what equipment they have touched, and where that equipment is at the moment. Apple and big tech companies are working on that for consumer. We have solutions, but more importantly, we need to continue to evolve that inside of the hospital system. It’s critical when you have something like COVID-19 or Ebola that you know where things are, whether they are usable, and who is coming in contact with them.

The pandemic seems to be accelerating the health system acquisitions that create sprawling regional or even national enterprises. How do you respond as your customers get bigger and move into business areas that don’t involve traditional hospital operations?

You respond by listening, even though that is a bit of an obvious answer. We also try to educate ourselves to become healthcare experts. We spend a lot of time talking to outside interests, outside experts, and trying to understand where we should push, advance, and lead through thoughts and action.

We saw two things advance during the pandemic. We saw not only telehealth and the inevitability of pushing healthcare out more directly into the community, but we also saw an evolved need for inpatient facilities. We had been moving away from that over the last decade as we attempted to decentralize healthcare, but all of a sudden, we saw this need to ramp up quickly.

As a software vendor, the key is flexibility. Are we making core investments in the things that we do well today? Are we making core investments in technologies that allow us to be flexible, like contact tracing and interoperability, things that allow us to move where healthcare is and to bring our solutions and services where our customers need them, not where we think we’ve designed them to operate? That’s a critical piece.

Do you have any final thoughts?

We hope that investors and users will give us the opportunity to display how a traditional ERP company can become central to a mission. It’s not enough to upgrade technology, create a better user look and feel, and deliver greater functionality in its traditional sense. We can be accretive to the broader picture of healthcare by providing this healthcare operations platform that helps balance out that ecosystem, works together with clinical, and advances the overall mission of the organization. That’s what Infor is looking to do, and we invite others to speak with us and give us that chance.

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.