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

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

Tell me about yourself and your job.

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

What does a chief digital officer do?

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

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

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

What organizations are doing digital transformation well in healthcare?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

HIStalk Interviews Patrice Wolfe, CEO, AGS Health

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

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

HIStalk Interviews Jeffrey Wessler, MD, CEO, Heartbeat Health

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

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

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

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

Will you integrate wearables, EKG, and monitoring solutions?

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

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

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

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

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

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

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

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

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

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

How does the model work from an insurance perspective?

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

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

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

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

Do you have any final thoughts?

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

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

HIStalk Interviews Jay Desai, CEO, PatientPing

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

Tell me about yourself and the company.

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

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

How widely are ADT notifications being used?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

How would they meet the requirements without using PatientPing?

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

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

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

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

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

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

Do you have any final thoughts?

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

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

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

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

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

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

Anu

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

Eric

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

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

Eric

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

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

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

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

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

Anu

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

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

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

Eric

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

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

HIStalk Interviews Diana Nole, CEO, Wolters Kluwer Health

Diana Nole, MBA is CEO of Wolters Kluwer Health.

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

HIStalk Interviews David Fast, President, Agfa HealthCare North America

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

Tell me about yourself and the company.

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

How much of the company’s focus involves imaging?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

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

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

Tell me about yourself and your new job.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What are the most pressing informatics priorities at Vanderbilt?

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

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

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

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

Do you have any final thoughts?

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

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

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

HIStalk Interviews Dennis McLaughlin, VP, Information Builders

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

Tell me about yourself and the company.

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

What are the most pressing analytics needs of health systems?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

HIStalk Interviews Angie Franks, CEO, Central Logic

Angie Franks is president and CEO of Central Logic of Sandy, UT.

Tell me about yourself and the company.

I am a healthcare technology veteran. I’ve been in the tech industry for over 30 years. I found myself in this position as CEO of Central Logic after serving on the board for close to four years. The board made the decision to take the company in a different direction and it was a good time for me, career-wise, to step in. I don’t think I’ve ever had more fun than what I’m doing today.

I like to use a couple of phrases. One is healthcare access and orchestration. It’s about moving patients into the health system via acute care, inter-facility patient transfers. Think about a patient who is in a rural facility or one that doesn’t have the appropriate level of acuity to take care of their needs. They need to be moved to a facility that is more appropriate for their condition. We take all the friction out of that process and make it easy to move a patient from one place to another.

What is the process involved with moving a patient from Facility A to Facility B?

With or without our system, it’s always a phone call. The sending physician and the accepting physician get on the phone and have a conversation about the patient to make sure that the patient is in a state where they can be transferred safely. Because the minute the accepting physician says, “Yes, we will take the patient,” they are responsible for that patient’s care until they get to the receiving facility. They are then part of the care team for that patient. If something happens to that patient, you want those conversations documented and recorded.

Without our system, there’s a phone call to the hospital system, into a call center, transferred around, bounced around, nursing station, phone calls back, lots of time delays, and a back-and-forth process before you can get to a decision of, “Yes, we can make that transfer happen.” When you put in technology, workflow, process, and access to data that we enable, you can take what might have been 10 or 15 phone calls and three hours to get a patient transferred down to a phone call or two and 10 to 15 minutes.

What does the receiving hospital review, other than clinical information, before deciding whether to accept the patient?

A transfer center agent takes the initial call. It’s a clinician, usually a nurse, or it could be an EMT. They identify the physician on call who should take the call and make the decision.

There’s the whole clinical piece that you just referred to. Where does the patient need to go based on the condition that they have? Then, do we have availability in this hospital or somewhere else in our system? Identifying that location, making that decision to say, “We’re going to place the patient in this bed, so hang on to that bed for this incoming patient.”

Then there’s the logistics of how we physically move the patient to the system, ordering the transport and getting all of the logistics done for the physical move.

Enabling all of that through one phone call and one number is what we do. When your health system makes it easy for other health systems or for other providers to send an acute care patient to you, you become the first phone call they make every single time. At the end of the day, this is a revenue-generating function for a health system. It helps bring in patients, it brings in the patients they want to bring in, it brings in the right level of acuity to support service line strategies or whatever the growth strategy is for that health system. When you make it easy, the sending facilities call you every time.

What are the primary sources of inpatients other than a hospital’s own emergency and surgery departments?

There are three primary sources — the emergency department, scheduled procedures, and the transfer center. When you don’t have a transfer center, a greater mix of your inpatient admissions come through the ED, which is a reactive way of building volume and driving patients into your health system that you seek to acquire and retain.

When you put a transfer center in place, you start strategically shifting the mix of patients that you have coming in the front door of the health system. More of those patients come in through your transfer center from other facilities that don’t have the ability, the room, or the capabilities and then send those patients your way.

It’s very attributable. It’s a tremendous ROI for every patient who is transferred into the system. When we work with health systems, we look at their current benchmark or baseline volume of transfers and compare that to where they should be given their size and their demographics. We can accurately predict the growth impact of putting in a transfer center, within a narrow timeframe on when they’ll break even on the investment for this type of solution. We can tell them what the net contribution margin impact will be in Year 1, Year 2, and so on.

In the entirety of my healthcare tech career – EMRs, ERP, and physician practice management — it was always a message of better, faster, cheaper. You’re trying to sell an intangible, the soft ROI of efficiency. This is the only time that I can truly say the value proposition that we bring to the health system can be forecast financially and and attributable down to a patient. It’s easy to track and document.

From a clinical perspective, you get superior clinical outcomes when you get people to the care that they need in an efficient timeframe. The patient’s life is in the balance when you’re in the midst of a transfer. These are not healthy people who just need a referral. These are people who are really sick, and they’re sitting in a facility where they can’t get the care that they need. When you can shave an hour or two or even 20 minutes off that transfer time, it can mean the difference between life or death for the patient, or it can mean the difference between a high quality of life after they’ve come through this medical situation and something much more compromised.

How will expanding health systems and the move to value-based care change how health systems manage their available beds?

As we make that shift to a more value-based care environment, this is all about giving the facility and the health system more control over helping the patient or their provider make the best clinical decision as to where that patient needs to be for the care that they need. You can’t manage and control that for high-acuity patients without the transfer center. Otherwise, who is coordinating the care? What is the fulcrum or the point inside that health system for helping make the decisions that are in the best interest of the patient and the system’s capabilities to deliver appropriate care? This is the function inside the health system that would make those decisions in a value-based care model.

I would add that the data that is captured inside of the platform, the technology that we’re providing, is so robust that it allows the health systems to make strategic decisions about capabilities that they should be offering, geographic areas that they should be serving better where transfers are coming or demand is growing, and services that they’re getting asked for that they don’t have the capability to deliver or maybe that have a higher demand than their ability to deliver. It’s a myriad of data elements and trends that allow executives, typically the chief strategy officer, to make strategic decisions for service line offerings for their health system or geographies that they should be serving.

What clinical information does the receiving hospital get from the sending hospital?

The information that is captured comes form the call from sending physician to accepting physician or to the clinician that takes that call. The Central Logic technology becomes like the EMR for that patient transfer. It’s all of the medical record around what status that patient is in when the call comes in. We have clinical protocols built in so you can rapidly capture all of the information about the patient’s current state and any other key clinical information that is relevant, and then the call between the two physicians. All this information is recorded and codified and a summary of that entire transfer record is passed as a PDF into the EMR. There’s always a record of the entire transfer end to end.

That has some pretty significant liability issues associated with it. If you don’t have these calls documented and you don’t have the entire decision-making process captured, you are opening up your health system to exposure to EMTALA violations. Also, oftentimes you can’t document in the EMR for a patient who doesn’t have a chart in your system, and most transferred patients are new to the health system. You’re exposed if something bad happens when you decline a transfer and you don’t have a way to document that the call came in. If the patient’s family sues the health system for denying the transfer and the patient passes away — and we’ve seen cases like this — and there’s no documentation that the call ever happened by the accepting facility, you can be liable for that decision with no documentation to back up why you made it.

You want and need to have a place where you can accept the call, document the condition, save that information, record the conference call between the physicians, and then maintain that record for the longevity of the patient, either in the patient’s chart or in the transfer record transfer system, in the case of of a denied transfer.

We talk a lot about interoperability, which often means sharing past visit records when a patient presents to a different facility. Does the receiving facility get the patient’s active chart, or something like it, from the sending hospital so they don’t have to start over and repeat tests and trying to understand a situation that has already been analyzed?

I just wish that we were at a place, interoperability-wise, where that was seamless. But the reality is that it just does not happen in today’s world. The information would have to come from the sending facility’s EMR. We have to inter-operate with just about everybody because it is fundamental to what we do. We’re talking to parties inside and outside the walls of the health system to facilitate a transfer on every single call. We have had 10 to 15 million patient transfers through our platforms. To broker the data back and forth between the the sending facility’s EMR and the accepting facility is not a problem technologically, but we’re just not at a point in the industry where the systems talk to each other like that. I’m going to just say that in today’s world, that does not happen. It is the information documented on the call.

I have to admit that in my entire health system career, I knew nothing about hospital-to-hospital patient transfers. They always just looked like admissions.

I would echo what you just said. After 30 years in the industry, until I joined the board, I had never even heard of a transfer center inside of a hospital. In fact, it never occurred to me to even think about how patients get to the hospital for the care that they need, outside of the emergency department and scheduled procedures. This is a channel strategy for health systems, but it’s not intuitive. It’s not something that we think about.

Do you have any final thoughts?

We’ve probably had more of a, ”If you build it, they will come” mentality in health systems. This is a more retail-like mindset. “We built it, we have the plant and the facility and the delivery capabilities, now  go out and get the patients in the door who need to be in our health system.” It’s a big financial reward and a clinical outcomes reward for that patient and a much better clinical outcome for the individual. We make it easy.

HIStalk Interviews Charles Corfield, CEO, NVoq

Charles Corfield is president and CEO of nVoq of Boulder, CO.

Tell me about yourself and the company.

I am CEO of NVoq, which is a Boulder, Colorado based technology company. We are active in the HIT space. We provide end customers and technology companies with voice recognition services to help them in their workflows, or in the case of software developers, to incorporate speech recognition into their products and enhance the experience of their  own users and customers.

What is left to accomplish with speech recognition now that it has become ubiquitous and of high accuracy?

There a still quite a lot to be done in terms of accuracy. You need the speech recognition to respect the domain in which somebody is talking and how they want the results to come back. That may vary from somebody who is getting the results directly back in front of them to somebody who may be a transcriptionist incorporating this into some other work. Or indeed, in the case of software developers, what they would like extracted from the recognized speech for their own programs. There is still a lot of post-processing work to be done. 

I should put in the caveat that it’s easy to confuse speech recognition from mind-reading. Remember that a computer CPU sitting there has not had the social immersion that a human has had. It doesn’t watch TV, it doesn’t go to the pub, it doesn’t get into arguments. It is very easy for us to project onto a computer CPU all sorts of human attributes which it does not have. Part of our skill as a technology company is to set the appropriate expectations amongst consumers of recognized speech as to what’s really going on and how to leverage it best for their own purposes.

Do the sellers of consumer-grade voice assistants try to make them seem smarter than they really are?

That depends what your end user experience is. Many people can have the experience on the one hand that it nails something, but then it appears as dumb as bricks at the next point. It’s no fault of the technology. It’s simply there are limits to what it can do. Because it is missing social context, the recognition mistakes are still there. I don’t think humans are in any danger of being replaced by these digital assistants anytime soon.

Has technology advanced to the point that computers can mimic human interaction?

You have to be careful that you get what I might call the clever dog trick syndrome. You can train a dog to do all sorts of interesting acrobatic tricks, but it’s extremely narrow what the dog can master. You are still left with that question at the end of the day, having been very impressed by what the dog can do — how does it pay the rent? There’s a versatility that humans have. Most humans who have walked the planet, and we’re talking adults here, have got a couple of decades of social immersion under their belts.

We should be cautious that we don’t over-hype what the machines can do. If we keep the machine’s focus on fairly narrow tasks, there’s plenty of opportunity for rote tasks to be automated and, shall we say, narrow social interactions to be automated. But if I might be somewhat tongue in cheek, artificial intelligence has a ways to go before it catches up with natural stupidity. [laughs]

Will ambient clinical intelligence, like that being developed by Nuance, be able to extract data from an encounter and allow the physician to work hands free?

Again, it’s a question of the focus. In doing the speech recognition in different environments, audio environment is not really the issue. It is, what are you trying to extract from what you have recognized? In fact, if you go back to a paper that Google published a little while back, they noticed in their own tiptoeing into this arena of ambient recognition that the problem was much, much harder than they initially thought. It comes down to all those other environmental cues about what is going on.

The computer is like the proverbial story of the blind man encountering an elephant. The computer sees the trunk, or the computer sees the tail. It’s hard for the computer to get the whole picture. Whereas the human, who is apparently so much slower and less able than the computer chip, actually readily digests the social cues as to what is expected and makes very good predictions in that environment.

Computers will get better at that, but I think we should be cautious that we don’t over-hype what they can do today. The best one in the world, even the biggest GPUs out there that are used for artificial intelligence, the amount of memory and processing power at their disposal is actually quite limited. I can stack up your common garden bee against one of those GPUs and note that the bee, with a brain the size of a pinhead, is able to communicate to other bees the location of food sources, navigate to those food sources without killing too many pedestrians on the way, and land upside down in reverse on that moving parking spot. You know, not bad. [laughs] Let’s not get carried away here.

That gives you my philosophy. I grew up in a culture where it was drilled into our heads that we should focus on meat and potato problems. [laughs] In other words, don’t get carried away. Go after the real meat and don’t be too proud to tackle what may, on the surface, seem too simple a problem.

You’ve said you don’t use speech recognition yourself even though some, including me, would say you are the father of it.

In my private life, I’m pretty low tech. About as high tech as I get is when I’m in my workshop making up a new pair of running shoes. [laughs]

As a vendor in health IT, how do you view that marketplace and the recent changes in it?

It’s a marketplace which is going to evolve enormously. The acute space is undergoing a lot of changes. Then there is a growth in post-acute and ambulatory going on. What you are seeing is the issue of data privacy, where consumers are now perhaps getting a little concerned about things they find scary about state-sponsored surveillance when they read stories about what is going on in China.

What about private sector surveillance, which if anything in America, is even more intrusive than government sector surveillance? Then combine that with the hackers who are busy ransacking every healthcare clinic or HIT provided to those healthcare clinics. They’re busy trying to loot them for as much ransom as they can get their hands on.

The issue about data privacy and security has become enormously more important. Without naming any names, some notable HIT vendors themselves have run into trouble on that score. For me as a vendor, it’s certainly one of the things that I spent a lot of time thinking about – how to put as many obstacles in the way of the black hats, and when and if your day comes up, how to limit the amount of damage that they can inflict.

Health IT vendors are partnering with big tech companies like Google, Amazon, and Microsoft. Should they be worried about getting too close to technology companies that are a lot bigger and smarter than they are?

There’s always that concern that, “Are you going to be road kill on the information superhighway?” as it was once put. The concern you’ve got is where Google is trying to open up partnerships with some of the larger healthcare providers to get access to their records and Cerner went through some sort of heartache over whom to partner with on that because of this issue. Will they just get disintermediated? I can’t say that I can look in the crystal ball and give you an answer to that, but it’s a concern.

For us as a vendor, the old mantra is that you want to be outside the kill zone. In other words, do not do something which is right in the target of what the major platforms are going to be doing. Do something which is differentiated, which is not worth their while to do, but which they would like to have as part of their ecosystem. That’s our approach. You’ll get to see over the next few years whether we’re right or wrong.

What has happened in the last couple of years with NVoq and where do you see the company going in the next few years?

It’s a bit like that old BASF tagline. “We don’t make the products you buy. We make the products you buy better.” There is IP know-how and what have you that we can bring to the table for the people who wish to incorporate voice into their own product offerings, where we can save them an awful lot of ramp-up time and we can save them from a lot of missteps. So for us, the next a few years is going to be a story of the partnerships that we build out there and the value that we can add to other people’s stories.

You developed the technical document processor FrameMaker over 30 years ago and sold it Adobe 25 or so years ago. How does it feel to know that software you developed generations ago is still being used and sold today?

I had the privilege of being connected to the engineers who now maintain it a couple of few years back. As I talked to them, we eventually ended up talking about some of the algorithms in it. What I found interesting was here we were all these years later and I said, “Well, haven’t you just rewritten all that stuff for something better?” And they said, “No, actually your original algorithm is still state of the art.” [laughs]

And then I had this thought. I wonder if it’s going to be a point that, should make it into my eighties, that I’m going to be speaking to some other engineers, finding out what sorts of things I’m worrying about today are either stupid or still state of the art? [laughs]

Maybe well-designed algorithms don’t have a shelf life.

You have no idea at the time. You’re simply just trying to crack a problem. There’s no textbook you get to look it up in. You do the best you can and then you have to move on to the next thing. It was kind of an interesting calibration experience, getting decades-later feedback like that. [laughs]

I saw in the infinite font of knowledge of Wikipedia that you have a species of lizard named after you. Who makes that call to let you know?

Goodness knows. [laughs] I think somebody with a wicked sense of humor. I will take it as a compliment and hope there’s nothing too horrible about the lizard or whichever reptilian species it is. [laughs]

Do you have any final thoughts?

In the world of HIT, it’s going to be a very exciting time, technology-wise. The impact of the cloud is going to come to bear. Even within an area like speech recognition, which has been around for a very long time, we will see a lot more application of it in different workflows. It’s the proverbial, “You ain’t seen nothing yet.” If you think about it, the number of people who are actually using voice recognition within healthcare is quite limited compared to the total number of people — consumers, clinicians, therapists, or what have you — who are out there in the field. 

I think we will see some very interesting value propositions emerge, and from a diversity of players as well. Keep your eye on some of the emerging startups, who may be just incorporating it into whatever newfangled clinical offering that they’re doing. It’s going to be an exciting time.

HIStalk Interviews Marisa MacClary, CEO, Artifact Health

Marisa MacClary, MBA is co-founder and CEO of Artifact Health of Boulder, CO.

Tell me about yourself and the company.

I co-founded Artifact with my partner Meir Gottlieb in 2014. Artifact is first to market with a solution that makes it easier for physicians to manage an important administrative task for the hospital — clarifying physician documentation for accurate coding.

The query process has a huge impact on the hospital’s quality data and reimbursement. Typically this task is extremely burdensome for physicians. It’s the last thing that they want to do in their day. We at Artifact Health have tried to change all that. We’ve taken this burdensome task and made it lightning fast and easy. The result is happier physicians, better quality scores for the hospital, and accurate reimbursement.

How extensive is the problem of hospitals having to ask doctors to provide answers to CDI and coding queries?

It’s extremely common. All hospitals, large and small, struggle with this process. Today in most hospitals, physicians are interrupted by CDI staff with these questions about their documentation. They are fielding the questions by email, fax, handwritten notes, or perhaps in the in-basket or message center for Epic and Cerner users. Typically it’s a time-consuming, multi-step process that physicians find very burdensome. They often ignore it because it’s not directly correlated with patient care, or at least it’s not the top-of-mind goal that they have for that day.

My partner and I have been working in healthcare IT for all of our careers, specifically, designing software systems for physicians. Through that, we have a lot of appreciation and empathy for clinicians. We saw this process as one that could have a better, faster, and easier workflow. So much for the hospital hangs upon it in terms of their quality scores, their rankings, and their reimbursement.

That’s why we decided to narrowly focus. We wanted to build a standalone platform that could work across any EMR system, any coding system, and address this one very big and important problem, which is the physician query workflow.

What is the mechanism for physicians to receive these messages and respond to them?

We decided to make the main mechanism the mobile app, because we felt that that was where healthcare was moving as one of the technologies that was going to become important to physicians. We made that decision early on. I remember in early conversations that people were saying to me, “Physicians aren’t going to want to use their phone to answer queries.”  We bet on that. We started developing in 2014.

That has been the most delightful and pleasing delivery mechanism for queries. They can answer them any time. A lot of the feedback we receive is, “Wow, you’ve enabled me to make my downtime productive. I can answer queries when I’m in an elevator or walking between meetings.” It’s so much easier for them to do that than having to log into the EMR and all of the steps that it would typically take to respond to a query. Now we can distill that down to a 30-second action on their mobile device.

Do they just leave the app open all the time? Is in intuitive enough to use so that not a lot of training or setup is needed?

We built it intentionally so that providers would not need to be trained. It’s something that they can download and immediately know how to use.

They don’t leave the app open, typically. They’re notified through a variety of ways from Artifact that they have open queries. They can be notified by email, text, or push notifications to the phone. Then they can stay securely logged in for a period.

It’s very fast and easy for them to open the application and respond, but we also were cognizant of physicians who might not want to use a mobile device. We have an ability for them to go to the website and answer over the web. Also, we’re integrated with some EMRs, so that when they’re charting, they can also click over to answer queries in Artifact. We give them a variety of ways to access Artifact and respond to queries.

Can they answer most of the queries off the top of their head or do they need to have the chart or documentation open?

When a query is sent to a provider, the clinical documentation specialist or coder is required to enter supporting information for that question. They have that supporting information in front of them in Artifact when they answer the question. We also have the ability to attach documentation from the EMR, so they can pull up a progress note or a discharge summary and review that before answering the question.

I would say about 95% of the time, they do not have to go back to the chart to respond to queries. For some very complicated patients, it might require them to do that, but most of these questions are pretty straightforward and they can answer them quickly and easily.

What feedback do you get from physician users?

They actually call it joyous. We were launched at Johns Hopkins, where we got started as part of their Joy of Medicine initiative as a give-back to the physicians. They are actually really delighted by it.

We also have a gamification piece. We track them and show them their scores compared to their peers on response rate and response time. We’ve gotten so much positive feedback about that that we just recently added an ability for them to share their scorecard over social media, just because they enjoy that. We made it fun for them.

For physicians, there’s not much fun in the technology that they use today. The fact that they can get something done and resolved is huge for them. Getting it off their plate quickly has been the key to their happiness. We hear that across the board from all of our customers. That’s been the deciding factor for many of our customers to move to Artifact.

How important is it that AHIMA and other groups have standardized the queries?

That’s an exciting part of our business as of recent times. We forged those relationships early last year and it has proved to be well received by our customers. Hospitals are building and creating their own templates or they rely on the expertise of their CDI staff and coders to create compliant queries. The query is the greatest compliance risk in CDI. Hospitals can be audited for and penalized for sending leading inquiries. There are many examples of that.

Hospitals are very concerned about being compliant in their query workflow. Having expert organizations like AHIMA and HCPro come in and provide templated queries that are written in a non-leading way, and to help them understand which clinical information they need to be entering into that query to help the provider answer it appropriately, has been such a relief. 

Our customers see it as a huge burden lifted for them. It takes away the time they spend putting together these templates, but more importantly it allows them to enforce standardization across the organization. Some of our larger customers, such as hospital networks, are trying to get control of their facilities by pushing out standardized templates to everyone and then being able to track them. That is a huge asset in helping them manage the risk of being compliant in this workflow.

What lessons have you learned about communicating effectively and efficiently with physicians?

We’ve learned a lot. Much of it was from our history of working with physicians for years. It’s also looking at the tools that they have at their disposal today, which they often say feed burnout and take time away that they could be spending with patients.

We’ve learned that just like anybody, they want things to be easy, especially when it comes to administrative tasks that take them away from patient care. It seems obvious, or at least it was obvious to us, that we needed to design something that made this a simple and fast process. Whenever we are designing a new feature in Artifact, we always have the physician as the first stakeholder in mind and think about how that physician would want this to work.

With every decision we make, we err on the side of what will make it easier and more pleasing for the physician. That’s important. Physicians are tricky customers. You have one shot to get it right for them. One strike and you’re out. 

That was probably the hardest part of building this application. Building something simple is actually quite complicated, and being able to get it right the first time so that you’re adopted is essential for hospitals then who are pushing technology out to their physicians. Physicians can kill a pilot in a minute if they don’t find it useful.

That was probably our biggest challenge and I’m happy we were able to accomplish it. A testament to that is that we haven’t changed the physician application very much over the years since we launched. We did our homework and got it right the first time.

Do you see an opportunity to take what you’ve learned and extend it into other forms of physician communication?

It’s a good question, because once we go live at a customer site, that’s always the next question they have. “What else can we drive through Artifact? We’ve engaged our providers in a way that we’ve never been able to do before. What else can we throw into Artifact to get done?”

We are very careful about that. As one of our advisors said to us, “Don’t step on the joy.” What he meant by that is. “It’s absolutely joyous that I’m barely cognizant that I’m in your application. I’m in it quickly and I’m out. Don’t make me hang out in it.” There are a lot of opportunities for expansion of Artifact, but we’re extremely careful about the ones that we’re going to take on.

The easy ones are when hospitals are coming to us and saying, “We also have queries on professional fee billing that we want to send out. We also have queries now in the outpatient environment, especially with value-based care payment models on HCC coding.” It’s been an organic expansion for us starting off in inpatient coding, but physicians demand that all their documentation-related queries come through Artifact because they find it so easy to use.

That’s where we’ve seen the most expansion of our product within our customer sites. But I do think there’s applicability in other areas and we’re absolutely looking at that for sure, and across other industries as well.

Will artificial intelligence, machine learning, or natural language processing affect what you do?

It’s not an area that we’ve dived into quite yet. But an interesting AI application is CDI prioritization. It dovetails nicely with our approach. In essence, it allows a hospital to identify cases where there is a very strong query opportunity. Having that piece of technology bolted on to Artifact makes a lot of sense, because you can queue up that query opportunity and Artifact then allows you to deliver it and take it over the finish line. We definitely see that as an application worth exploring in the future.

Do you have any final thoughts?

We are at the beginning of this, where our standalone application allows us to continue to work with customers across all different EMR systems and coding systems to help enhance this workflow. It’s an important culture shift that happens within hospitals when you give physicians technology that they find easy and convenient to use. Our goal at Artifact Health is to continue to build software solutions that appeal to physicians and to help hospitals and practices achieve their goals as well.

HIStalk Interviews Al Lewis, Workplace Wellness Skeptic

Alfred Lewis, JD is an author of several healthcare outcomes books, operates the website, “They Said What? Because the Wellness Industry’s Pants Are On Fire,” and is founder and CEO of Quizzify of Waltham, MA.

Tell me about yourself and what you do.

I am CEO and quizmeister-in-chief of Quizzify, which is a an employee health literacy company. As we say, wiser employees make healthier decisions. However, I believe we are having this conversation because of my personal blog, which is called, “They Said What?” in which wellness vendors, diabetes vendors, and related vendors are critically analyzed to in fact show that they usually don’t achieve what they claim to achieve.

You’re offering $3 million to any company that can convince an impartial panel that their program can save employers money. Do you have concerns about having to pay up?

None whatsoever. The entry fee is $300,000, and believe me, it’s worth taking a one in a million shot with this impartial panel of five judges, of which I only get to appoint one and the burden of proof is on me. They don’t have a chance, which explains why nobody has tried to take me up on it.

Is it lack of knowledge or intentional deception that motivates wellness companies to sell services to employers without having sound science behind them?

Confucius put it very well. He said, and in those days it was all gender specific, that, “When a man makes a mistake and it’s pointed out to him and he doesn’t correct it, he is telling a lie.” So at this point, these folks know they are lying. They have made the gamble, and it’s a good gamble, that vastly more people are going to read their ads that are going to read my website. So what they do, and they’ve gotten very good at this in the last couple of years, is simply ignore my postings instead of responding to them so as not to create a news cycle and a whole discussion.

Is the available science good enough that they could do it right if they really wanted to?

I would say that for wellness generally, it is mathematically impossible to save money. There are not enough wellness-sensitive medical events. Even if you were to reduce 100% of them, you could not pay for most wellness programs. I’m not going to say it’s impossible, but it has clinically never even gotten close to that 100%. The typical reduction in risk is 0%, somewhere between minus 2% and plus 2%, while you would need a mathematically impossible 100% to 150% reduction to break even.

Most vendors are counting on the fact that most employers have absolutely no idea how many of their employees go to the hospital every year for diabetes. I could tell you if you like, unless you want to take a guess. Out of 1,000 people under the age of 65, how many go to the hospital with a primary diagnosis of diabetes in the insured population?

I’ll say two.

Actually, that’s very close. It’s more like one. Occasionally I run health and wellness trivia contests at conferences. How does the radiation in the CT scan compare to the radiation in an X-ray? But I also throw in that specific question. If you added all the diabetes events and all heart attacks together in a typical employer population, what would the rate be per thousand? In fact, it would be two, if you put both of those together. The guesses that I get are usually somewhere between 20 per thousand and 200 per thousand.

What about the perception of the incidence of chronic disease in general?

It’s not my take, it’s the world’s take. Because I do this show of hands thing, I do these trivia contests all the time. The employer benefits community thinks it is between about 20 and 200 of these events per 1,000 employees. Which of course makes no sense whatsoever. This is just what they say because they get bombarded with information talking about all the people who have diabetes and all the expensive chronic disease. Let’s take those two things one at a time.

A lot of people do have diabetes. They may not even know it. It’s not going to become an issue for them for many years after they find out. If in fact an employer intervenes, they may possibly be able to control it. But what they’re doing is saving Medicare money down the road because virtually nobody goes to the hospital with diabetes before the age of 65. Yet employers want to start paying for medication for these folks, so it’s a net increase in cost.

And then your other point of chronic disease. I’ve written extensively on this fallacy that 86% of cost is chronic disease. If you read it carefully, you’ll find that they are saying that that 50% of adults have chronic disease. Now if you’re defining chronic disease that broadly, you’re including a whole lot more things besides the things that a wellness vendor can get to. You’re including arthritis. You’re including hypertension. Who doesn’t have hypertension?

If you put all that together and say, “Let’s count every dollar that someone with hypertension spends on healthcare.” So someone with hypertension breaks their leg, you count that. You probably don’t even get to 86%, but most of that is also going to be in the over-65 population. In the under 65-population, the major drivers of costs are birth events and musculoskeletal.

The wellness vendors have done a great job of moving the goalposts. It used to be they would say, “You’re going to get a three-to-one financial return.” Then they started saying, “You’ll get a one-to-one return.” Now they’re saying, “There is really no financial return, but the employees will be healthier.”

If you actually look at the health of the employees … I’m not going to name names, except to say that there are a handful of vendors, generally the ones validated by the Validation Institute, that get more than a trivial improvement in health. There are other vendors — and I don’t mind naming names, Interactive Health and Wellsteps come to mind — where employees actually get worse as a result of these programs.

If that’s the case, won’t those companies eventually get fired for failing to deliver?

Some number of them are getting shown the door, but new employers are coming in. The problem is that the vendors have figured out how to measure outcomes fallaciously in such a way that most employers and most consultants aren’t going to catch them. They compare participants to non-participants, for example. It’s been proven up, down, sideways, backwards, forwards, and eight ways to Sunday that every iota, every dollar of savings in a participant versus a non-participant comparison is due to the mindset of the participants versus the non-participants and not to the program.

How do I know that? There are several data points. Studies have benchmarked those things and found exactly that. But the most dramatic one is a company called HealthFitness Corporation that did a wellness program for a company called Eastman Chemical. They separated the groups into participants and non-participants in Year Zero. But due to a whole bunch of incompetence and delays, they didn’t get the program started until Year Two. By the time they started the programs, the participants had already dramatically outperformed non-participants.

The funny part about that is that my nemesis, the Snidely Whiplash to my Dudley Do-Right or the Lex Luthor to my Superman, was stuck with this, so he moved the goalposts. He said, “Oh, we overlooked that. That was our bad. We weren’t competent enough to realize that the program had actually started in Year Zero, not in Year Two. Therefore, you don’t know whether it’s due to the participants or non-participants.”

That turned out to be a big enough lie. And I don’t mind saying, oh, I’ll say on the record, Ron Goetzel is a liar. He can go ahead and sue me. The difference between him and me is that if he calls me a liar, I’ll have him in court the next day.

They put out a graph that shows suddenly that the program started in Year Zero, not Year Two. The people who actually did the program got upset enough with that. If you go back and look at the website now, they have in fact replaced the lie with the truth, which is that the program started in Year Two after dramatic savings had already been found.

You’ve made the case that the simplest way to measure a workplace wellness program’s success is to ask the people who signed up if they participate regularly and see benefit from it. Do most programs fail even that basic test?

There is a tool put out by the Validation Institute that is the most elegant tool for measuring the cost-effectiveness of programs that I’ve ever seen. We are big supporters of it. You ask employees two questions. How much did you use something? You may not even have to ask them that because you already know. Then, did you find it useful? Then you multiply the number of times somebody used something times the usefulness they found. That gives you an engagement score as your Y axis. On the X axis is the cost of the program. You plot the engagement score against the cost of the program and you can tell in a single graph how cost-effective your programs are as viewed by employee use, employee engagement.

You’ve come down hard on Livongo. What concerns would you have as an employer who is considering buying their their program?

I would have two ethical concerns. One is that what they called a study that they point to is essentially a paid ad. The study was done by their employees and their suppliers’ employees. They don’t say anywhere, “We paid thousands of dollars to have this study published.” If they had disclosed that, that would be acceptable. Marginally acceptable. But to essentially take out an ad in this schlock journal disguised as a study, I have an ethical problem with that.

The other thing I have an ethical problem with is that that journal did do a modicum of peer review. Not remotely as much as I’ve done, but a modicum. And they said, “There is no causality here. It is only correlation. There is a correlation between having a Livongo program and having a reduction in costs.” Livongo put out a press release that said, “This study delivered a reduction in cost,” which is a lot different from a correlation. You cannot ethically take the word “correlation” and turn it into the word “delivered.” Those are my two ethical problems.

I have some arithmetic problems as well. The two things that you should measure if you’re trying to figure out if in fact you have reduced the severity and the incidents of diabetes are, number one, what happened to insulin use? Insulin use has actually been declining because the price has gone up so much, so it shouldn’t be a heavy lift to show a reduction in insulin use. Meaning you’re getting some diabetics off of insulin, which is a cost savings, and it also shows that the type 2 diabetics are improving.

Number two, you say, how many fewer diabetics went to the hospital for diabetes than they did previously? That’s a very standard plausibility test that the Validation Institute uses, that Health Affairs has used. It’s in my book, “Why Nobody Believes The Numbers,” which was a trade bestseller when it came out if anybody wants to look at it. It has never been challenged.

Either Livongo did not know enough to measure the two primary outcomes of a diabetes study — which are, did you reduce the use of insulin and did you reduce the hospitalization rate for diabetes – or  they measured them and they did not disclose them. Neither of those gives confidence in Livongo.

The third thing is that their first study said they got a 59% reduction in inpatient, which essentially means that they wiped out every single inpatient admission that did not involve birth events, trauma, cancer, or mental health. Every single one. Their second study made absolutely no reference to inpatient, but said that physician visits and physician expense went down by 26%. So essentially they had two studies, and when they put out the second one, they conveniently forgot about the first, which essentially said the opposite. That’s a red flag.

The other red flag is that every single other wellness vendor in the universe looks at physician visits and physician expense as a good thing. You’re getting people to go to the doctor more. It’s questionable whether that is a good thing, but that’s what everybody looks at. You’re getting people to go to the doctor more, so they’re doing more prevention, et cetera. The idea that you could be titrating all these diabetics’ meds, managing all these diabetics, and somehow have vastly lower physician expense is something they would have to do a great job of explaining to me.

That brings us to the final item, which is that some of what they do appears to be in conflict with other guidelines. This is also in my company Quizzify’s diabetes Q&A, which is reviewed by doctors at Harvard Medical School and carries the Harvard Medical School shield on it as a result. That is, that type 2 diabetics should not obsess with checking their blood sugar. That’s more of a type 1 thing, to check your blood sugar every few hours or every day or something.

It’s quite clear that there is no difference in outcomes between type 2 diabetics who do that and type 2 diabetics who check it vastly less regularly and just have a healthier lifestyle. They don’t have any kind of sentinel events, like a change in their meds or a big change in their weight or some kind of medical event of some type. You just don’t have to check it that often.

But Livongo brags about how many times they get their type 2 diabetics to check their blood sugar. Maybe it’s a coincidence or not, but they are allied with companies that provide medication and other supplies to diabetics. So I would have them explain why they are doing something different from what the literature says.

The manufacturer of Oxycontin pitched their product in referencing a friendly, somewhat obscure research letter that wasn’t peer reviewed. That’s what drug companies do – cite the positive papers in their advertising even if they are scientifically shaky. Is this a healthcare problem beyond just wellness programs, where we aren’t critical enough consumers of literature?

The Oxycontin thing was kind of funny. The doctor was not getting paid to say it and he was actually specifically referring to patients who are already in the ICU. They found something that happened to say what they wanted to say, and like you said, they ran with it.

This one is a little different, because they basically paid a bunch of their employees and they got their suppliers to write this article. Then they paid a journal to publish it. The payments to the journal have never been disclosed to investors. It does say who wrote the article. It does say that the employees and the suppliers wrote the article.

But here’s the thing. Most people, when they see the term “peer reviewed,” that checks the box for them. That says, “Oh, this is legitimate.” But I could give you 15 or 20 peer-reviewed articles in the wellness and the diabetes literature that are essentially incorrect on their face.

Anybody can challenge data. The issue is invalidating data. Can you look at data, and on its face, prove that it’s incorrect? With most wellness data, you can. In fact, I often say in wellness that you don’t have to challenge the data to invalidate it. You merely have to read the data and it will invalidate itself.

Many of those studies are peer reviewed, and many of never should have passed peer review. Oftentimes there are entire journals out there like the Wellness trade journal that have never asked me to peer review anything because they know true peer review would just shoot down everything that they put in it.

Employers talked a lot about coalitions and group purchasing to reduce their healthcare costs, but they haven’t accomplished much. Are wellness programs a half-hearted attempt to rein healthcare costs without addressing provider charges?

Let me take that question and put it into two parts. One is that wellness was very easy to put in place. You could say to your CFO, “Oh, look, we’re doing wellness. This will solve our problems.” Because for wellness, you didn’t have to negotiate with your suppliers or anything like that. You just layered in a new cost item and claimed that it would save money.

A guy by the name of Dave Contorno in our industry, a very capable guy, says the way to save money is to spend less of it, not to add on programs. Like Yogi Berra once said, “We don’t know where we’re going, but we’re making good time.” It was a panacea. There was even a guy — I don’t mind telling you his name, because he said it publicly — by the name of Bruce Sherman, who claimed in a conference that wellness could reduce industrial waste. When you get to that level, you’re just in fantasyland.

The second point that you made is, what should employers do? I would direct you to a book by a guy by the name of Dave Chase. It’s called “CEO’s Guide to Restoring the American Dream: How to deliver world class healthcare to your employees at half the cost.” He points out that, in fact, you can reduce costs by 20 to 40%. It’s been done. It’s not a question of finding solutions — the solutions have been put into place. It’s just a question of putting these proven solutions into place. Things like reference-based pricing and employee education, which is of course what we do. There are new levels of new types of pharmacy benefit managers that don’t have these massively complex contracts with all sorts of rebates that the employers never see, but rather just take wholesale prices and mark them up. All sorts of things have been done. All you have to do is do them and you will see. 

When I work with David Contorno or Dave Chase, I use a little formula with them. Which is, X plus Y equals 20%. X is the reduction in cost and Y is the increase in employee satisfaction with the healthcare program measure, however they want to measure it. Those two figures will add up to a 20% improvement. So if you really want to ratchet your costs, you can do that with no improvement in employee satisfaction. Or at the other extreme, if you feel that a really good program is great for attracting employees, you can keep the cost the same but then basically create low co-pays and  low monthly contributions and get your employees much more satisfied with the program.

HIStalk Interviews Joe Petro, CTO, Nuance

Joe Petro, MSME is CTO and EVP of research and development with Nuance of Burlington, MA.

Tell me about yourself and the company.

I got into health information technology about 15 years ago. I started with Eclipsys, on the executive team running R&D. About three years after I was at Eclipsys, I got a call from Nuance. They had a smallish healthcare division and they were looking to go much deeper. I joined as healthcare senior vice-president of R&D. We’ve grown this business over time to about a billion dollars.

Nuance has two divisions. Two-thirds of the company is basically healthcare, while the remaining one-third is enterprise. About 18 months ago, I took over as a chief technology officer for everything. I do all of the products, the technology, and the research as well.

What progress has been made on ambient clinical intelligence and the exam room of the future as conceptually demonstrated at HIMSS19?

Ambient clinical intelligence is super exciting. Five or six years ago, Carl Dvorak at Epic was having a conversation with us and floated the notion of a room being able to listen. At the time, we didn’t have any necessarily tangible connection with how we were actually going to accomplish that. As conversational AI and other technologies developed, we started to get a firmer notion around what the exam room of the future could look like.

A lot has happened over the last 12 to 18 months. We have a number of clients now in beta, so we are learning from real feedback from real physicians. We have made a number of advances in terms of the state of the art and in terms of that summarized document that is produced by the conversation. From a tech point of view, that’s an intergalactic space travel problem in terms of how hard that problem actually is. We are jumping from a broad, basic, human-to-human interaction to a finely-tuned clinical document. From a tech point of view, we have advanced the state of the art.

We have also come up with the second generation of the ambient listening device that sits in the room. That second generation is being rolled out soon.

We definitely do not have a demand problem. Just about everybody in the industry has reached out to us, either as a potential partner or as a client. It’s a super exciting time.

A research article addressed the difficulty of turning an exam room conversation, especially in primary care where it might include social elements and cover multiple diagnoses, into clinical documentation. What are the technology challenges?

In the basic inside-the-tech, Russian doll part of it — getting inside and inside and inside – you are layering together accuracy levels on the entire problem. The first thing you have to do is diarize the speech, separating the multiple speech streams in the room. It might not just be the physician and the patient speaking — it might be the physician, nurse, patient, and the patient’s family.There’s a signal processing and a signal enhancement problem associated with that. That in and of itself has its own accuracy challenges. Then you have to turn that into text, and casual conversation is different from the more controlled clinical conversation.

We have 500,000 physicians on our Dragon Medical One product. That formal conversation has accuracy rates of something like 95, 96, or 97%. When it becomes more casual and conversational, it’s a different kind of a challenge because the text and the concepts aren’t necessarily well formed.

The next step is to extract facts and evidence, so you apply something like natural language processing, AI, and neural nets. You extract things like diagnoses and the active medication list. You try to associate things with the patient’s history versus the current issues that are going on with the patient. 

Finally, you jump to the summarized document. That’s a big jump, because if a patient is talking about the fact that they hurt their back changing a tire, that may or may not end up in the clinical documentation at all. Based on the data we collect, we decide which things to include in the documentation and which shouldn’t be there.

The flow I just went through involves, from a Nuance point of view, the last 20 years of technology that we’ve developed. Each one of the problems alone is hard, but all the problems together are even harder.

Is the technical challenge of multiple voices and accents less of an issue than when systems needed to be trained on individual voices and users had to speak closely into a microphone?

With the introduction of artificial intelligence, a lot of things have yielded. But it’s not just the AI on the software side of things. Inside that device that hangs on the wall is a linear microphone array. There is something on the order of 17 microphones in there, lined up and separated by a small distance. When you think about the capability of each one of those microphones, think about a cone that is emitting into space from each one. The software and the signal enhancement technology behind the scenes, which is AI based as well, figures out who is in the room and who is actually talking. Then with voice biometrics, we can identify that person and keep a lock on them even if they’re moving around inside the room.

That’s one of the breakthroughs that we’ve brought to this space. We have been in multiple industries for a long time. This has been going on in the automobile industry, as an example, for quite a long time. We actually just spun out our auto business and that has had speaker diarization in it for quite some time, where you’re identifying the person in the driver’s seat versus the passenger versus the variety of children and family members who might be in the back seat. That problem was cracked some time ago and we brought that battle-hardened technology over to the healthcare space.

Wouldn’t there be easily harvested clinical value in simply capturing the full room conversation and storing it as text to support searching, either within a specific patient or across all patients?

Yes, for sure. When I’m talking to the executives here or the executives at EMR companies or even physician or hospital execs, one of the things I always try to explain is that as we get deeper into this problem, opportunities are going to reveal themselves and present themselves to us for augmenting present-day solutions with things that we learn during the ambient clinical intelligence process. We have already had discussions about making the transcript available.

There are pluses and minuses to this. You always have compliance issues and whether physicians and hospitals want this thing hanging around as part of the record. But I think we’ll get through that and figure that out with everybody. But for sure there are things that we’re going to introduce, such as making that conversation available, making the diarized speech available, making the facts and evidence that are intermediate results available. We are having these conversations in an ongoing way with all the electronic medical record vendors, just to figure out what intermediate artifacts we might be able to produce along the way that have high value.

It’s one of the things that makes this exciting because it’s almost like gold mining. You are constantly discovering these things that have tangible value and you can introduce them as part of the product offering.

The excitement over extraction of concepts and discrete data from voice in the room overshadowed the ability to control systems hands free. Is it widely accepted that voice-powered software commands could improve usability?

It’s a little lumpy, to be honest with you. From a Dragon point of view we’ve had what we call Command and Control, Select and Say, voice macros, and these types of things for quite some time. Now we’re evolving this to what we call conversational AI, which allows you to do what you just described in a more conversational way. You can say something like, “Dragon, show me the abnormal lab values,” or “Dragon, let’s pull up the latest imaging study,” or “Dragon, let’s send something to the nursing pool.” It’s more conversational and it could potentially be interactive.

Whereas in the old days, and actually in the present day for the most part, with Command and Control, you’re using a voice command to trigger some kind of a keyboard accelerator that might be available through one of the EMRs. You’re trying to execute a rigid macro that checks off a bunch of boxes. The rigidity of all that, and the brittleness of that, is evolving to something that’s quite flexible. 

We’re at a tipping point now where, as you say, is there wide recognition that this could be really good? A certain segment of the population, like the advanced users of Dragon, have always been using this and think of it as rote. They’ve been using it, see the power in it, and realize how it can affect their lives.

I think what’s going to happen now is that we’re going to get past that early adopter phase that we’ve been stuck in for quite some time. There will be broader acceptance the more natural that experience becomes. It’s breathtaking how natural conversational AI can be now. Again, we’re bringing over technology from our auto business and our enterprise business that has been doing this for huge companies for a very long time. All that conversational AI expertise is coming over.

You’re going to see some really big advances here. I’m personally super excited about what’s going to happen over the next couple of years in terms of what we call virtual agents. That’s a very exciting territory.

Will consumer acceptance of voice assistants make it easier to get EHR users to use something similar?

It lowers that barrier, where someone might feel awkward interacting with artificial intelligence and doing it on a day-to-day basis in a natural way. The more that speech becomes ubiquitous as a primary modality that folks interact with, either artificial intelligence or some kind of behind-the-scenes systems, the more the barrier is lowered for us.

I was at a physician’s office the other day and someone had their phone turned up to their mouth and was dictating. The insertion of punctuation into dictation is so unnatural and awkward, but it’s amazing that the person was just sitting there doing the dictation. That type of thing creates relief on our side because it doesn’t feel so awkward for the physician to do it. It also doesn’t feel awkward for the patient to observe the physician doing it. It lowers those artificial barriers that used to be there. I think you’re right — that does create a certain luxury for us.

How do you see speech recognition and synthesized speech being used for population health management?

It can come from both sides. Voice-enabled systems allow folks who are interacting with those systems to to pull information out of them by telling the system what they want. You have a knowledge worker on one end and then the patient side, the reporting, and the things that we could capture from a social point of view that could end up in systems like this. You’re going to see a lot of territory covered in terms of what is actually available to patients.

We’re going to have to address PHI and all of that stuff in terms of what ends up in these systems, how it ends up, and how the patient opts in. But once we get through that phase of it, you will see a lot more entry points that are voice controlled. They will be on both sides of it. You’re going to get the speech side, which is pushing things in in a natural way or trying to extract something with a natural expression of a query. Then you’re going to have the interactions from the patient’s side, which are also voice enabled, but it’s all going to be conversational AI based. You’re going to be talking to a system that asks you questions.

An example of that might be if you ask the system to query something, and it’s an incomplete thought, the system can ask you using voice synthesis — what we call text-to-speech – for whatever it needs to complete the thought so that it can get the appropriate level of information. You’re going to see that all over the place. It’s a bunch of tech that sits around the periphery that will be involved as well.

What impact do you see with EHR vendors signing deals with cloud-based services from Amazon, Google, and Microsoft that give them access to development tools, and I’m thinking specifically of Amazon Transcribe Medical?

It’s another entrant. We keep track of everybody that’s out there. Google has their version of that, Microsoft has their version of that. It’s a good thing to see all the cloud players getting involved. It allows us to create clear differentiation between what we do and how we do it, the accuracy and the fidelity of the experience.

We think about the speech problem as being much bigger than just providing speech to text, and that’s what a lot of these SDKs do. In Dragon, there are literally hundreds of features that sit above the speech dial tone.

The more entrants, the better. That competition is a good thing, but it’s just another competitor type of a response from us.

What opportunities does AI create in going beyond transcription and voice commands to extracting information?

The Comprehend piece, the natural language processing piece — the ability to reach into a stream or a blob of text or documentation or whatever and extract facts and evidence — has been around for a long time. It’s not a new concept. But it allows you to make intelligence part of that natural interaction, which is so important.

For example, we’ve been generating queries to physicians in what we call Computerized Physician Documentation. That’s based on AI. It’s based on natural language processing and it’s also based on speech. It allows us to put intelligence into what we call the speech dial tone, so that as you are speaking, we are aware of the context of what is going on with the patient because we have access to that information through our EMR partners.

But we also know what you are saying. If you’re doing a progress note and you make a statement about some condition, we can connect the dots. If there is specificity missing, if a hierarchical condition category got triggered in the ambulatory setting, if there’s some piece of information missing that could lead to a different diagnosis, we can present that information to the physician in real time. This is making the experience both natural and very, very rich, because the more data we bring into it, the more it takes the burden off the physician.

Physicians are under massive cognitive overload every single day. If we can relieve that a little bit through these mechanisms, it will be a really good thing. Things like Comprehend Medical, the stuff that Microsoft has, Google, the stuff that we have — I think it will all move things in that direction.

Do you have any final thoughts?

We are really excited about the future. I’ve been doing this for a long time now, and I’ve never been more excited about what we’re doing. Ambient clinical intelligence definitely provides an opportunity for Nuance, working with EMR partners, to advance the state of the art in terms of the patient and the physician experience. We are all about the healthcare mission and we are all about relieving burden. What we’re doing here will improve life for all of us as patients, and the partnership with Microsoft and so forth definitely advances that. It will definitely accelerate our mission to get there as quickly as we possibly can. We are jazzed about it and we are really excited about the next few years.

HIStalk Interviews Laura O’Toole, President, Santa Rosa Consulting

Laura O’Toole is president of Santa Rosa Consulting of Franklin, TN.

Tell me about yourself and the company.

I’ve been with Santa Rosa Consulting for 10 years and have played many roles here. I’m a passionate person. I pride myself on being a good mother and I live my life every day with gratitude and an appreciation for our industry because I’m a breast cancer survivor.

Santa Rosa is a professional services company that focuses on outcomes-based solutions for our clients. As of late, we are leading with more niche and meaningful services that we think our clients need to pivot to in continuing to be successful.

How did your experience as a patient with breast cancer change your perception of the healthcare system?

It has changed it a lot. It has certainly given me more appreciation for the importance of integration and communication among providers. That was a point that was very frustrating to me. Even as well as I can navigate the system, it also got me to see, upfront and center, how important it is to be an advocate for yourself. As a patient, you have to make a conscious choice to engage in your own care.

As somebody who has grown up in this industry and made it my whole career, it gave me a sense of empathy and almost a sadness for patients who don’t know as much as I do and the number of their questions that don’t get answered along the journey of being sick.

But mostly it gave me an appreciation for this industry and for what we all do. I do believe all of us — regardless if you’re a vendor, a professional services company, or whoever you are in this space that serves patients — want what’s best for patients. We as an industry have an obligation to do more to keep that patient at the center and to focus on the importance of clinical workflow.

It changed my life being sick, frankly. It made me look at everything differently. I live my life with a level of gratitude that I never had before. There’s still a lot to do in our space to make it better for patients.

How did you see the importance of technology as a patient versus what you expected?

Technology is the cornerstone of the building and at the center. Even as someone who operates every day in health IT, I never realized how important it is. If clinicians and providers could embrace technology as much as their IT counterparts do, we would start to see some real magic.

How has the demand for consulting services changed in the past few years?

The landscape has really changed. We have seen that as some firms are still around and some aren’t. Back in the day, everybody was focused on Meaningful Use because there was a lot of opportunity. I believe now that the healthcare professional services space needs to continue to put their clients at the center, but specifically to define value-add, niche, or bolt-on services.

So many of our clients now have implemented their core EHR. How do you take them to that next level? The consulting firms that can provide the most value to their clients are the ones that are looking out past where our client is today and listening to the client and what isn’t working for them.

We think the timing is right for test automation. Our clients simply cannot meet the escalating demand for the comprehensive testing that is required of the complex IT ecosystems that we’re seeing, along with the frequency of upgrades and releases from their EHR vendors. Clients don’t have the money or the resources to have armies of people, additional testers, and pulling their subject matter expects out of their day jobs away from being out in front with their business partners solving problems.

I believe that niche offerings like test automation — built from the ground up exclusively for healthcare and workflow centric — can give our clients more time, more energy, and more focus on their projects and patients. This is where the services for consulting companies need to go.

Integration as a service is critically important for our clients. Being able to fill a client’s needs just in time and to help them on the talent curve is also important.

The company does a lot of Meditech work and that company has made big changes to both its products and leadership team. How will their new professional services offering affect your business?

Certainly a large part of our business is around Meditech. We are a 6.1 Expanse partner. We have a detailed implementation methodology. I think we are the only firm that is confident enough in our delivery that we can provide that implementation on a fixed-fee basis. Meditech is transforming their business and their company. I believe they will be one of the three players left standing.

It’s interesting to me that they have focused on professional services. We believe it’s better to have an independent third party supporting our clients. We believe it drives better outcomes for our clients and that the client should always be at the center.

That said, we have great appreciation for what Meditech is trying to do. We will work alongside them, and with them, to continue to serve our clients and to do what’s right. I love the Expanse platform. It will take many of the Meditech clients that move to that platform to a whole other level of interoperability and care for their patients, so I commend them.

Are your clients asking for help with the industry’s move to the cloud?

Anything that we can do, or that vendors can do, to support interoperability for clients is the right thing to do. If you think back even if a few years ago, we had big health systems not wanting to share data and vendors not wanting to share information. But the constituents that need to share data are our patients and our clinicians. The more that we can evolve and support even bolt-on solutions or capabilities that provide interoperability is what is best. The cloud, and moving as much as we can to create a landscape that allows for more interoperability, is the right thing to do and what we all need to focus on. For our clients where that makes sense, that is our recommendation.

We also advise our clients that they need to look at other solutions and some bolt-on solutions that can take them up the delivery curve to best serve their patients and their physicians. It’s not always about the core vendor. Certainly that’s the cornerstone of the building, if you will, but there’s still a lot that can be done to make a difference and to get more niche services that can provide the optimum value.

How you determine the right time to develop a service line around a particular technology based on its maturity?

In professional services, it is “some days peanuts, some days shells.” You have to take the time to listen to your clients. We have built our company around several flagship accounts where we have done work from our inception as a company. We will continue to do that. We regularly talk with and use a core set of great talent within our client base to hear what their problems are, to try to get ahead of that curve.

There will be some that you will hit on, some that you will miss on. As I mentioned, test automation and the results and benefit for a client are just undivided. Clients like Novant Health, one of the leaders in the implementation of Epic, have realized dramatic improvements and time savings in their testing capabilities. They have been results driven and have the opportunity to reduce real risk in patient safety in clinical care and in revenue cycle integrity.

There’s a whole host of secondary benefits to that. Education and training. Everyone uses the word optimization. I don’t like that word, but taking their EHR up the value chain for their providers, for their clinicians, and improving data quality. If you focus on the core of what will make a health system successful and keep it around those offerings that can reduce time, save them money, and propel them into the future, you are doing the right thing for your clients.

You will always have some that that hit and some that don’t. You have to have a core base of flagship clients that know you, trust you, and know that you mean what you say and say what you mean. It becomes a personal commitment to serve them well. If you have that as the basis of who you are, you will do well, figure it out along the way, and as some offerings catch and some don’t, ride that wave and continue to do good work.

Do you see any little-recognized developments that could take the industry in a different direction?

I don’t see a tremendous amount on the horizon from a regulatory perspective as we did in the rear view mirror of the past. All of the clients that I talk to are trying to figure their integration and  governance strategy for telehealth. I think that will propel us. You’ll see a lot more in home health and outside the traditional box. Integration and integration as a service is an area we’ll focus on. 

You have to be able to plug and pull and have time available when a client needs it. They are just like us in going through ebbs and flows. There will be a dramatic need for high degrees of flexibility because our clients need to be able to provide quality care and some of them are struggling to get there without looking at the full landscape of everybody that is providing care in their ecosystem. Telehealth will be an interesting dynamic over the next several years.

Do you have any final thoughts?

I love our industry. All of us in healthcare want to provide value for our clients so that they can better serve their patients. Being a patient myself, I’ve gained such an appreciation for that and a gratitude for what providers and clinicians do every day to serve our clients. I look forward, as does Santa Rosa, to staying a part of that industry that supports care and makes a difference for people.

At the end of the day, we all have people who we love and care about that we want to see healthy. Healthcare is a beautiful place to be and I’m delighted to be a part of that industry and to serve it.

HIStalk Interviews Michael J. Alkire, President, Premier

Michael J. Alkire, MBA is president of Premier of Charlotte, NC.

Tell me about yourself and the company.

I’ve been at Premier for about 16 years, filling a number of roles. My current role as president is focused on driving the two big strategies that we laid out at the beginning of the year. We are technology-enabling the supply chain for our healthcare systems. We are also building out enterprise analytics, embedding machine learning and artificial intelligence into an analytics platform that helps our healthcare systems reduce costs, improve quality, and migrate to new payment delivery models.

What is the ownership structure of the company now that it is publicly traded?

Our healthcare system member owners hold 46% of the Class B shares. As of our last 10-Q filing in September 2019, we have 155 member owners. The remainder of shares are held by the public.

What challenges do employers have in managing their healthcare costs?

The rising cost of healthcare is the primary reason that large employers are looking for alternatives to how healthcare is provided to their employees. 

Our journey for Contigo Health started about 18 months ago. A very large, self-insured employer came to us. They spend billions of dollars on healthcare and believe that 20% of that spend involves unnecessary variation and waste in the system. They would call out things like wanting a total knee or total hip in Orlando done the same as it is in Fargo. The way they described it is that there’s huge cost variation and huge clinical outcomes variation. They had an interest in building a high-value network of healthcare providers, both healthcare systems as well as other providers, to participate in this network.

They provided interesting statistics. From an oncology standpoint, 10% of their employees who are diagnosed with cancer don’t actually have cancer. Of those who are diagnosed with cancer, 30% are placed on the wrong regimen. Not only is the patient not receiving the right medical attention, the employer bears a huge cost. The patient may miss work due to being on the wrong medication and then getting established on the right regimen. They use that as an example of lack of standardization of care across the country.

They also talk about OB and C-section rates. Somewhere around 30% of all US births are done via C-section. In western Europe, the C-section rate is 22% or 23%. CDC says that C-section rates should be near 20%. This employer studied markets in which C-section rates were more than 50%. This creates significant cost as well as significantly more risk to the mother.

The prevalence of data that is available to these large employers is helping them understand where variation is occurring. They are looking for a partner that can help them manage this variation. I think they came to Premier because of our history of using discharge data from 45% of all US hospitals and our work with physicians and their quality reporting to Medicare. They liked the idea that we have the data. They also liked the idea that we have been working in collaboration with our healthcare systems for the better part of 15 years in improving the standard of care.

Is it an awkward conversation to tell health systems, which may be Premier’s members or owners, that your employer customer thinks they charge too much and don’t practice evidence-based medicine?

When this large player came to us and we built this collaborative that was the precursor to Contigo Health, we reached out to 35 healthcare systems that represented 440 hospitals. We said, “Very large employers are interested in building this high-value network, but we need your data, your claims data, and your electronic health record data.” We had clinical and safety data for many of them, but we needed to build data capability for this initiative.

At least 90% of the folks who participated in those first meetings provided us with their data or their interest in sharing their data with us. I think their reasons are twofold. One, they know that the market is moving in this direction, where the necessity for care to be standardized across the country is an imperative to drive down the cost of healthcare globally. Two, being part of a high-value network provides them leverage when they are negotiating with the payers in their markets. Saying that they adhere to and implement these standards and that they use the highest, best capable analytics to implement clinical protocols will differentiate them in their markets.

I don’t think that the idea is that employers will demand lower costs. They see so much variation in how care is being provided that their interest is reducing waste and standardizing the approach to providing care, as opposed to a negotiated perspective of wanting procedures done at a lower cost. The initial goal is to create a high-value network of a high standard of care.

Does this involve offering fixed prices for certain procedures, and similar to what Walmart is doing, sending employees out of their local geography to receive care from providers whose cost or quality may be better?

Payers are providing a lot of ancillary benefits to the employees of large employers, who aren’t taking advantage of them. Think about smoking cessation. We have the ability, given our Stanson Health acquisition, to write detailed analytics into the workflow. Large employers are interested using these workflow protocols to help ensure that employees are taking advantage of the ancillary benefits that they have access to. When an employee meets with the physician, it pops up on the screen that they work for Employer X, which has a smoking cessation program that they would like this patient to enroll in. There’s a free benefit that’s helping them do that. We will focus on these ancillary benefits as we get the Contigo Health programs started.

Then I think there will be two parallel paths. We will create this high-value network for things like maternal health, which will be nationally based and will involve certain protocols that these large employers would like these providers to follow. Second is exactly what you said. Large employers like Walmart call them centers of excellence, where they send employees out of geography for specific services. There will be a path for that in the short term.

But I will tell you that unless it’s something that’s very serious, very rare, or where the expertise just doesn’t exist in the local or regional markets, these large employers have an interest in getting care provided as close to the patients as possible. You will have these centers of excellence in the short term and mid term. They are nationally based today, but you’ll see more regionality of these centers of excellence, where you’ll have them in pockets along the various regional geographies of the US. Eventually I think they will become more localized to the extent that those geographies actually have the providers who can provide those services.

Premier’s health system customers should have been able to recognize and address their clinical variation given the reports you send them that highlight it. Why did employers have to apply the financial pressure to make them take action?

We work with some of the largest IDNs in the country, many of which span states and regions. They have their own focus on driving standardization of care across the entire healthcare system.

As healthcare systems are moving more towards taking downside risk, it’s imperative for them to standardize the way that care is being provided. It provides a benchmark for them to improve from. For quality outside of healthcare, such as in the automotive or high tech industries, you want to have that basis way to produce product, use that as the baseline and then always innovate off of that baseline. That’s what healthcare systems are attempting to do when they are trying to create that baseline. It’s two- sided risk.

Second is the movement to ACOs and capitation. A number of our healthcare systems that are creating partnerships with ACOs know that they have to be on the hook to provide standardized care across the communities that they serve.

The final driver will be differentiation. I spoke about this earlier in terms of their leverage with commercial health plans, but organizations that can prove that they are standardizing care and can prove that their outcomes are different than the big brands in their markets — or in some cases, bigger and smaller systems in the market — are the ones that are going to be the winners in the long term.

All of this is going to become transparent. That’s the fourth aspect, that healthcare systems are becoming aware that their outcomes are going to be transparently shared with the communities that they are serving.

Clinicians don’t always believe or follow evidence that is accepted elsewhere, or they think evidence needs to be tailored to local practices. How will you weigh the available evidence for a national group of health systems that haven’t followed it so far?

Stanson Health’s CEO is Scott Weingarten, MD. He was CEO of Zynx, which was all about creating standards of care, trying to standardize different protocols, and those kinds of things. They have had a very successful run. We were interested in Stanson because it takes those clinical decisions that come from the analytics and embeds them into the workflow.

For the first time, you will see a lot of this evidence-based clinical decision information show up in the workflow, when the physician is practicing or at the point of having conversations with their patients. They will see the clinical evidence at their fingertips.

The tool itself is unique. If organizations don’t want to use it from a proactive standpoint to provide alerting and other capabilities to the clinicians during the time of care, then a function on the back end can audit whether clinicians are following standard protocols that they have set up. Technology has allowed us to take this issue to the next level, both in being proactive at the point of care and to understand whether clinicians are following the standards of care.

Do you have any final thoughts?

Premier is working to fix US healthcare from the inside. We believe that healthcare needs to be consumer centered and provider led. Leveraging the providers, the data, and the analytics that we deliver to providers, along with the ability for them to collaborate, is the best way to solve our national healthcare issues.

HIStalk Interviews Michele Perry, CEO, Relatient

Michele Perry, MBA is CEO of Relatient of Franklin, TN.

Tell me about yourself and the company.

Relatient is based in Franklin, Tennessee, and was started in 2014. Our name is a combination of “relate” and “patient,” relating to the patient. We are 100% focused on patient outreach and engagement, and it reflects in our name. We do this only for healthcare. We get calls all the time to see if we do this for prisons, courts, schools and everything else, but we are focused on patient engagement.

I joined in 2017. I replaced the original founding CEO. I’m a Saas software solutions veteran. I focus on high-growth companies.

I’m not a Nashville native, which you’ve probably already heard based on the lack of R’s in my vocabulary. I’m originally from Massachusetts and have spent time in New York, California, and Virginia. I was in Annapolis, Maryland for the 20 years before I took this job.

Are hospitals and practices wrong in thinking that all consumers really want is a patient portal?

Patient portals served an important purpose. They were part of the Meaningful Use requirement. But they are not addressing the needs of today’s consumers and patients. Find me a patient who thinks they are.

We compliment a lot of the work that has been done with patient portals and the investments that have been made in them. Lots of times we’ll drive people to things that are stored in a patient portal. But we’re all about using that phone and making it easy for patients.

In this day of the consumerization of healthcare, we all expect to be able to access things easily from our phone. Every day I’m making reservations, planning a flight, calling an Uber, checking my bank balance, and Venmo-ing money to my kids. You can do it with just a couple of clicks. Try to make a doctor’s appointment, check for your lab results, or register for that appointment while you actually have the medicine sitting in front of you at home. Try to do any of that stuff and it’s painful.

That’s what we’ve set out to fix. We make it easy for the patient, and if you make it easy for the patient, you make it easy for the practice. We see hospitals and clinics and everybody else wanting to engage with their patients.

What are the ones that are doing a good job doing differently from those that aren’t?

I’d love to say that it’s concentrated in different areas, but it’s not. We are seeing it across all specialties. Nebraska Cancer in the oncology area is using it to reduce no-shows by 47%. I was surprised – don’t cancer patients show up? The answer was that we need to alleviate the confusion around all the different providers and appointments people have during the cancer treatments.

We are co-presenting with Oklahoma Heart at HIMSS on driving patient engagement in a mobile-first market. We have FQHCs like Access Healthcare in Chicago, who wants to be able to message not just about your appointment, but to let you know that the food trucks that take SNAP are going to be there on the day that you are there for your appointment. Pediatrics organizations like Children’s of Colorado are doing interesting things with telehealth and remote access initiatives, reaching out into rural areas. Primary and women’s care, like Seven Hills or South Bend Clinic, are focused in gaps in care and things like that.

What percentage of hospitals and clinics are using electronic appointment reminders?

The first generation of those products was pretty basic, and it’s rare for us to run into somebody who hasn’t put in a first-generation solution. But now that they have it, they’re finding that they can do so much more with that communication. Do I need to fast before my appointment? Do I need to show up extra early for testing?

Some of our large hospitals have 120 kinds of appointment types, each of which require different messaging. They need support for multiple locations, especially now with telehealth and remote health, so they can say, “Your appointment is with Dr. Smith out of the Denver office, but you are going to be in the Grand Junction office.” The second generation of products needs these kinds of communications. But it’s really rare to find someone who hasn’t done a first-generation product, except for some small two- and three-doctor offices.

Why is patient self-scheduling uncommon?

Practices didn’t have it yet. They said, “Oh, we have a scheduler.” But people want to be able to schedule after hours, during lunch, or during conference calls. I want to quickly make that appointment off my phone or off my desktop. I want to be able to do that quickly. People hadn’t set those up.

We also found providers who wanted their front desk people to have ownership of that schedule. We’ve added to our product the ability to have a two-step acceptance. Let me make my appointment at 10:30 at night. When my kid’s not feeling well and I want to make an appointment, let me make that appointment. But let it actually have to be accepted by somebody in the office in the morning. They accept this one, accept that one, and then realize that they’re accepting all of them anyway, so they are comfortable skipping that step. But the ability to have ownership was important for a couple of our providers as we were bringing them on.

On the back end, does someone have to copy-paste from the self-scheduling application into the system that keeps the real schedule?

The way we do it is important. We actually write back into these schedules. People are sometimes kind of scared about it upfront, but then when they see that it works really well, then they give up. But yes, we don’t just send an email that someone has to then set up – we do all the write-backs right into the systems for appointment reminders, scheduling, e-registration, surveys, and all of the other components.

The culture of some hospitals and practices was built around a siege mentality, where patients aren’t allowed to communicate with a provider unless they make a billable appointment and come to the office. Is that changing?

Sometimes you can bill telehealth appointments, to have those paid for. People want to have access to their doctors, so they’re trying to make it easier to do these new types of appointments, because if I don’t make my physicians accessible to you, you’re going to go down the street to the urgent care or some other clinic. They would rather not have them go away to the Walmart clinic, the CVS clinic, or someplace else. They want you to come to their providers.

Your system offers broadcast messaging for unplanned changes to normal operating hours, like weather emergencies. Do practices who don’t have it just update their Facebook page and hope patients check there?

Some of the folks still change their websites or have a message on the answering machines. We have tremendous demand for demand messaging, or the broadcast messaging capability, when you have weather problems, like New England this week or during Hurricane Dorian. But it’s also used for non-weather things, like if a doctor will be out for the next two days on bereavement, or in OB-GYN for messages like, “This doctor was just called in for a delivery. Please call the office before coming to make sure they will be here for your appointment.” Specialists make appointments months ahead, so you have to keep up to make sure that you’re not blasting the whole patient base to get a message to the 20 patients who need it.

What about health campaigns such as disease-specific follow-up or seasonal items like vaccine availability?

There’s nothing we do that you couldn’t do manually, but it takes a lot more effort. Campaigns to close the gaps of care are important, especially in primary, women’s care, and pediatrics. Getting people back in to make sure their kids are getting the right vaccines at the right time.

We’ve learned the hard way how to actually do the notifications. Maybe 3,000 patients haven’t had this particular thing that needs to get done. If we just blast everybody, your call center gets overloaded the next Monday. We do a dribble campaign and send the messages in bunches so they don’t all go out at the same time. We pull the data from the EHR and practice management system, use the campaign to contact those people and get them to make appointments, and with patient self-scheduling, we can send them to the link so they don’t even have to call the office.

Consumers vastly prefer text message communication over all other forms for convenience, but it also offers better deliverability than email or phone calls and also gives patients a way to take action without writing something down.

What we have found, and what we recommend in our best practices, is a combination of all three. We do phone, email, and text, and we do them at a certain interval over time. We don’t want to stalk you, but we want to make sure you get the message. If you do just texts, your response rate will be lower. If you’ve heard it on an answering machine and you’ve seen it in the email, you might not have reacted to it, so it’s a combination of seeing those.

We send the final reminder at certain times of the day. Some at night, some in the morning, depending on time of your appointment. You might have accepted it and intended to go, but you drive to work and forget. But if I send you a text that morning for an appointment later that day, you’ll remember. I also can’t send them too late because you don’t want to be disturbing people at night and when they go to bed.

Do you have any final thoughts?

We’re still early on with patient engagement, how we’ll engage patients over time, and how we’ll do it within the constraints of HIPAA, GDPR, and other regulations. It will be exciting to see where this will go, with things like two-way chat. But as we do this, we’re committed to innovation. Not just product innovation, but throughout our company. We’re currently rated number one by KLAS for patient outreach, with a score of 95.6. We follow this score closely throughout the company. We believe it’s the best way to ensure that we are firing on all cylinders. We need to have great products delivered by great people to work with our customers to drive the ROI on our software.If we drive that ROI, we will help our practices have happy customers.