HIStalk Interviews Scott Shreeve, MD, CEO, Crossover Health

Scott Shreeve, MD is CEO of Crossover Health of San Clemente, CA.

Tell me about yourself and the company.

I am an emergency medicine physician. I was one of the co-founders of Medsphere, the first open source enterprise electronic health record. It was built and based on the Veteran’s Administration software system that was in the public domain. We had a good experience commercializing that software for hospitals and health systems that couldn’t afford the Epics and Cerners of the world. We had some nice success and early wins. I left the company under some challenging circumstances, but I’m thrilled to see it go on to be successful.

After I left Medsphere, I became interested in healthcare delivery and primary care. I was doing a lot of reading about re-architecting and designing new types of health services. I had read “Crossing the Chasm” and “The Innovator’s Prescription.” Primary care has always been such an important part of the foundation of a good, strong, healthy healthcare system, and if we could design that primary care foundation in a better way, with new payment models and a new care experience, that could be the basis of some great innovation.

After speaking, consulting, writing, and blogging about those topics for several years, I decided to take the plunge in 2010 to start Crossover Health. It began as a direct primary care practice. We had some initial success after opening up our first store in Aliso Viejo, California, but quickly learned that going directly to the consumer was quite challenging. We pivoted our innovative primary care model to address the needs of self-insured employers. Crossover became the medical group that provides services to companies like Apple, Facebook, Microsoft, Comcast, and others. We’ve been on quite a run since then.

Crossover Health describes itself as a digital-first national medical group. How does that work in terms of access, provider licensure, and use of analytics?

Crossover is focused on Fortune 50 companies and Fortune 500 companies that are looking to bend the cost trends in healthcare, that want a different experience, and that want to get more involved in healthcare delivery. They hire us to do that. We’ll come onto their campus or near their campus to build these health services.

What we find, though, is that most of the employers we work with have scattered pockets of employees all over the country. We were addressing only 10% to 40% of their populations by building near their headquarters. That was great for the patients who had access, but it didn’t address the needs or solve the problems of all of their employees. What they’ve asked us to do, and what we were doing on our own, is to extend our care model by adding digital-first as a strategy to capture the rest of the population.

That move is critically important. Telemedicine has been around for years. A remote employee in Georgia might work for Facebook in Menlo Park, but they can pick up their phone to immediately access their dedicated care team for the designated Facebook population and get the care they need right off the bat. We can either address is then or have them follow up locally where they live in Georgia with a curated network of specialists.

We have built a consistent care team that is licensed in all the different states. It is available to the people throughout the country who are covered by the benefits of that particular employer. Because we’re not physically in Georgia, we then have to steer, navigate, and coordinate the care for them when they access care that they may need locally. 

It’s an interesting solution. We either come on your campus or near your campus and provide a set of services, but now we are meeting the patients where they are, and that is digital-first. People are comfortable coming online. It’s  how they work in the rest of their life. Now we’re allowing them to work with their dedicated care team in the same way.

Surveys have shown that Millennials love technology and the immediate gratification it can provide, but don’t have much interest in cultivating an ongoing relationship with a primary care provider. How do you work with those employees?

I love the quote that “nature finds a way.” Everyone finds a way to get care. Millennials are comfortable getting online and asking things. If there’s not a coordinated, organized way in which that happens, they will meet their needs their own way.

What’s fascinating to me is that when you give them the opportunity to interact with a primary care physician and a consistent care team, they love it. It’s simple to them. They want to establish a relationship, but it has to be convenient, accessible, and in the way that they normally live their lives.

Our technology isn’t an electronic health record designed for billing. It’s a more like Slack, asynchronous communication with a consistent care team, where we can have that constant communication as needed. Then guide them in their local geography.

We’re finding that Millennials really do care about their health, but they don’t care for the traditional system that doesn’t provide access and tools. If you can meet them where they are, it’s very effective, very powerful. They are used to picking up their phone, logging into an app, texting their provider with a question, getting a response, and then digging in deeper if needed or being guided and steered to a local, curated specialty group. They are very comfortable with that. That’s not foreign to them, that’s expected. We are having a lot of success with that population.

Each employer has their own fingerprint and demographics. Some have older employees, such as in manufacturing and retail. We’re finding that those people very much want a relationship as well, and they are becoming comfortable with the tools. It’s almost like you are looking at different ends of the spectrum. You have the Millennials, who are very comfortable with the tools, and by the way, the relationship is great. On the other end, you have “I really care about the relationship,” and by the way, the tools are great. It seems like we’re crossing the generations through this type of a care model.

What are the contrasts you’ve seen as a former EHR vendor who now has the luxury as a provider to build the exact systems you need?

We’ve always had an electronic health record undergirding the foundation. But we built our own patient technology. Our patients never see the electronic health record. They see our tools, our patient engagement platform. With Jay Parkinson coming on board and all the work that he’s done at Sherpaa, we are building more tools and capabilities for our team members, our provider groups, to interact in this more asynchronous, structured question way.

Most of the care that we provide is through asynchronous means. Someone says I’m not feeling well, so we get orientation of what that is through this asynchronous communication. Once we’ve narrowed it down to a diagnostic category, we’ll send a structured question set, say, for stomach pain. Patients will take their time to answer that back. Based on that feedback, we’ll take the next step. We may need to see them in person and we ask if we can schedule that right now, or it could be that we suggest waiting for it to declare itself over some period of time.

We look at the electronic health record as the Slack channel. Each episode of care that we open up is its own project. We have tools that are effective at managing projects. Over time, we see replacing bits and parts of the EHR infrastructure with this patient engagement tool set because we are so focused on that. That’s where we see the evolution with Jay and with Sherpaa coming on board. Jay has taken on the roles of our chief designer and is building and extending what he did at Sherpaa, on a platform that has both a digital and now a physical presence. That combination is where he gets to play and innovate now.

Why is there a disconnect between widespread availability of virtual visits and the low percentage of Americans who have used them?

We are finding that it is not in the human experience, certainly not in the cultural experience in America, to get on the phone for 10 minutes with a random physician that you have no relationship with. We see 2% to 5% utilization. There are clearly situations where that is fine and where it works for the 30 set conditions that you can manage. What we’re really talking about here with our model is full-blown primary care that has, as its basis and foundation, a physical visit that’s done a little bit differently. Better, we think. But now purpose-building in the virtual connection as well and delivering it in the same way.

It’s a known care team that now has new capabilities. It can extend to individual patients and interact with them in the way that they do in every other aspect of their lives.

Traditional telemedicine — when it is disconnected, when it’s a random physician that you don’t have a relationship with, and when it’s not endorsed from your provider — is only going to have a certain percentage of pickup. Our thesis has been that you can develop trust in a medical group that is endorsed by your employer; that you have met, touched, and felt; and that now has the ability to extend the technology to you. That is really powerful. The person is at home and can access us. They know us. We get back to them. We’re on call 24/7. They have this connected experience wherever they are in the country. That’s the difference that we are banking and betting on.

How do health systems that make big money selling those questionably necessary visits react when you sign on with a big local employer?

Comcast / NBCUniversal is a huge player in all these different markets. Every health system wants to cater to their business. Our other employers are similar.

A lot of the health systems don’t really know what to make of us. If your business is built on sick care and you’re dependent on me feeding your MRI machine, that business model is doomed. The health systems that we do have a chance to work with are really innovative. They are very much based on value-based healthcare. They are realizing that while having a incredibly full hospital has historically been a big part of their business, I don’t really want that for the overall health of populations and value-based contracting.

We’re somewhat of a nebulous group to interact with. Some know that it’s a great model and a great primary care foundation, but it’s also challenging for them to understand how to work with us. Some innovative health systems know they haven’t been able to change the fundamentals of primary care in their own markets, so let’s do something totally disruptive outside of our system, but in partnership with a primary care group that is value-based and will send us the right referrals. It might initially look like that affects our immediate, short-term bottom line, but over time, given the new financial models that they’re moving towards, this is exactly what needs to happen, and they are embracing and endorsing it.

How much of Crossover Health’s identity do health systems use when announcing those services?

Most health systems have a lot of equity built into their brand from the trust and years and decades of work in that community. We have the option, and we do this with our employers as well, to white label our services, so it is very strong on that particular health system or employer’s brand. We can go all the way to the other end toward Crossover, because there are advantages to being totally separate, new, and different. In different settings, the privacy and the security and having a separate entity provided is useful.

We find that most strike a middle ground, where they want to have their name. but also our name together. It becomes a “powered by” situation. We leverage the good name and goodwill of that institution or brand from the employer, the health system, and then you can also show and highlight that you have this innovative collaborative partnership as well. That’s where we see most people land.

You’ve been out of health IT for a long time, but how do you see that landscape developing, especially with regard to what investors are funding?

This is like a view from 10 years ago since I left the industry when I was following it closely, but a couple of comments, maybe. One is that I’m surprised, but also not surprised, that Epic essentially has eaten the entire medical space. I think Judy’s concept of having a fully-integrated, comprehensive suite and then being able to get ahead of that is amazing. The value of the integration has been greater than any limitations of their underlying technology or otherwise. That’s been impressive to see from the outside.

Conversely, these monolithic kinds of system are incredibly hard to work with from the outside. It’s not that they are so technically hard to work with, it’s that they flat out don’t want to work or integrate with other people outside. That’s the negative side of how big they have scaled.

It’s interesting to see where Cerner has continued to evolve, along with Allscripts and others. I’m still a huge advocate of open source technology and love to see that Medsphere and others are out there still doing it.

Where my perspective has changed is that I see healthcare IT as simply a tool. Whether I have this tool or that tool, it is a tool that enables the information, the sharing of information.

The problem I see with health IT as it is today is that if architecture is destiny, then the way that these systems have been architected is highly concentrated around billing and other things. They have added other clinical components that are important, but that overemphasis and tying it to a fee-for-service system, which I also feel is doomed, impinges on the potential impact of where healthcare IT can go. What we are working toward and building is trying to get things that are more consumer-centric, where consumers can be more involved with their care, the record is really theirs, it is shared with their provider groups, and they have modern tools for interacting with their care teams.

Where IT has always been strong and remains strong is that you can aggregate the data, analyze it, and provide advisory services back to the people who need it, both providers and patients. I am pleased to see where that’s gone and where it hopes to go with machine learning, artificial intelligence, and other ways to introspect the data that has been gathered. That is really promising.

One of our big collaborators is Health Catalyst. Some of these big-iron tools that do deep-dive data analysis for big health systems are getting to the point where smaller providers like us can access them and put them to work. So much of our care is not about reacting to what’s on our schedule that day, but proactively reaching into the population to find those people who we need to be seeing that day. Then using digital-first tools and otherwise to get the people who maybe are less acute, but still have needs. Can we address those another way so that we can reserve the in-person visits or our concentrated efforts on those people who need us most?

How can technology overcome the fact that health system consolidation and the involvement of huge for-profit companies have left patients dealing with ever-bigger and potentially more bureaucratic organizations in their moments of need?

Privacy and the value of healthcare data is incredibly important. How you manage it, and the trust and confidence that people have to have and who’s storing the data, is critical. We work with some of the biggest technology companies with amazing amounts of data on different customers and the lives of all the people who use their platforms. We’ve learned a lot from watching how they do that.

There needs to be a role for a new type of health service that you join that keeps you healthy, that is independent of CVS, Walmart, and the insurance companies. People could join an organization that is purpose-built to manage their health information at their request. Who will be the first health banking service that is a trusted, independent third party that can aggregate your data and that you can assign in a permissioned way to allocate access to your data at certain points in time? Whoever creates that is going to be powerful.

The future health economy will be built on the currency of trust. One of the things that we sell quite a bit to our clients and employers is that Crossover is an independent, tech-enabled, data-enabled, national medical group that is independent of payers and health systems. We are a potential candidate to become that trusted intermediator of your health data. To bank your health data in a way that you trust and to allocate and invest your health information based the permission and rights you have. We are excited to see where that goes.

HIStalk Interviews Kavita Bhavan, MD, Chief Innovation Officer, Parkland Health & Hospital System

Kavita Bhavan, MD, MHS is associate professor of infectious diseases at the University of Texas Southwestern Medical Center and chief innovation officer at Parkland Health & Hospital System in Dallas, TX.

This interview was conducted by Vikas Chowdhry, MS, MBA, chief analytics and information officer of Parkland Center for Clinical Innovations in Dallas, TX.

Describe how your career led you to become a chief innovation officer.

I started out as a graduate student in public health at Johns Hopkins and then pursued my MD at Penn State. After completing my residency training in Internal Medicine at Ochsner, I chose infectious diseases, at Washington University, as a subspecialty because it is an area where public health and medicine naturally interface. I joined the faculty at UTSW in 2009, working in an HIV clinic at Parkland.

Shortly after joining the faculty here, I was asked to work in a smaller capacity with a great team of pharmacists on ways in which we could improve delivery of care for uninsured patients that require long courses of IV antibiotics in the outpatient setting. The existing disparity between this group of patients and those with adequate insurance was that they could not access standard forms of outpatient therapy, such as infusion centers, home health services, or skilled nursing facilities.

Prolonged inpatient care is difficult for an individual patient since it limits their ability to return to work or care for family at home. It also impacts the safety net system, where many patients may be waiting to be admitted in the ER. We innovate in this kind of an environment out of necessity and can only succeed when we are given space to rethink care delivery with support from leadership and key input from frontline providers.

What does innovation in healthcare space mean to you?

Innovation in healthcare can present itself in a various forms. While many people associate technology with innovation, I’ve been increasingly interested in thinking about another aspect — low-tech, low-cost approaches to patient-centered innovation to address disparities and improve health equity. The most natural place to start seems to be effectively engaging patients in care processes to reconfigure existing resources to improve high-value care.

What does that mean? In healthcare, we often talk about empowering nurses, social workers, and physicians to practice at the top of their license. What does top of the license for patients look like? Innovation in healthcare includes co-designing care with patients to improve access and address other existing problems. Better clinical outcomes can be achieved with such co-production of care.

There is a shift that occurs when a patient is providing care for themselves at home, as in our home IV antibiotic program. They move from being a passive recipient of care in the hospital to being an active participant in their care at home. We have observed better clinical outcomes over the years while also seeing enhanced engagement and management of one’s health, including other chronic diseases such as diabetes.

Innovation is usually thought of as synonymous with technology. While technology is important, we need to make room for another model of innovation that is even cheaper and easier – recognizing human potential.

How does engagement that goes deeper than “use this app to check your lab results” or “use this device to report your steps” work in practice?

Our self-administered outpatient antimicrobial program at Parkland has become a new standard of care for our patient population and is an example of effective patient engagement. Typically, patients with infections that require long-term antibiotics receive intensive diagnostic and therapeutic services in the first several hospital days. Afterward, they remain in the hospital only to receive antimicrobial infusions.

Insured patients may be discharged early to complete their antimicrobial courses at home with contracted nursing assistance or in lower-cost nursing facilities, but uninsured patients usually remain in the hospital because they cannot afford a healthcare-administered outpatient parenteral antimicrobial therapy (H-OPAT, overseen by the healthcare system).

Those uninsured patients have limited options and may be confined to the hospital, which prevents them from resuming work or other activities of daily living or caring for family members at home. In the safety net hospital setting, this can be a challenge in terms of capacity and the ability to care for other patients, in the ER for example, as a sub-optimal use of resources such as beds.

We approached this problem by piloting our program with a few patients in 2009 with the goal to teach and train the method of self-administrated IV antibiotic therapy by gravity at home. We started the program with minimal resources as patients did not have a home visit or access to home health nurse, infusion center, or devices such as pumps / elastomeric balls (S-OPAT, overseen by the patient themselves).

We began with four patients as a proof of concept and have now cared for more than 4,000 patients through this program. Along the way, our multidisciplinary team listened and learned from our patients what works and what doesn’t work to further refine the process.

We translated education material to appropriate levels of health literacy for our population, achieving a fourth-grade literacy level in English and Spanish and including pictures. After a few years, we moved to an audiovisual process where patients can scan a QR code on the back of an IV bag and be sent to a teaching video on their smart phone where they can watch the process and review all of the steps for infusion at their own pace. This has been effective not only for patients who speak other languages, but also for those who prefer visual learning.

We developed a competency checklist, and using the teach-back method, had patients demonstrate all of the steps of infusion and PICC line care needed to ensure safe discharge from hospital to home.

After the first four years of operation, we tracked clinical outcomes for our S-OPAT patients compared to patients with insurance who left our hospital for healthcare-associated OPAT such as home health or skilled nursing facilities. We were surprised to find that our S-OPAT patients had a 47% lower 30-day readmission rate along with higher patient satisfaction.

How is that possible? When we talked to our patients on return visits, we found they mastered all of the steps and took ownership of the process. It was clear they were more invested with effective engagement. One patient actually said she thought she did better because “it is my own body” versus a nurse coming out to the home to perform a job. We began to appreciate the positive impact of patient engagement with meaningful results.

How do you scale the program?

One of the interesting aspects of this program was that after learning about the success of self-administration, other patients who were insured with access to healthcare-administered therapy wanted to participate in our self-administration process. I have since learned from others that this may fit a model of disruptive innovation. You create something that is useful for a small section, usually a bottom tier of your consumers, that eventually becomes attractive to the broader market. However, unlike a consumer market, adoption by the broader market is determined by a lot of other factors, including existing health policy, reimbursements, etc.

There has been other interest in promoting patient engagement as seen by the recent CMS position on encouraging at-home dialysis. The proposed ESRD Treatment Choices model will give patients an ability to choose at-home dialysis, which may potentially improve satisfaction, lower costs, and improve outcomes.

Could your work have been done at other institutions?

UTSW and Parkland’s partnership is unique because we are committed to caring for a large population of uninsured or underinsured patients with health disparities. Innovation centers attached to larger health systems may have greater investment in technology-based innovation. Our approach has been more patient centered. Our CEO, Fred Cerise, MD, MPH, described another way of looking at innovation that does not need to be driven by profit in his Harvard Business Review article a few years ago

We are likely in the minority coming from a safety net hospital in the larger healthcare innovation space, but there is a need to grow across the country since safety net settings innovate out of necessity.

What’s the most impactful book you have read in the last 12 months?

“The Moment of Lift” by Melinda Gates. She articulates the value of inclusiveness and educating and empowering women to fully recognize our collective potential as a society. There are examples of how impactful this can be around the world and here in the United States.

How do you remain optimistic as a physician when working with a population whose inequities and social disparities are root causes that you can’t address?

The problems are far reaching and there is no simple solution. We are increasingly aware that social determinants affect health and outcomes. Just because we cannot do everything to solve these problems does not mean we cannot do something, to do some small part to help address a given problem to improve the status quo.

I’m lucky to work in an environment where I and many others have the opportunity to make some small difference as we strive to improve patient care.

HIStalk Interviews Karly Rowe, VP, Experian Health

Karly Rowe, MBA is VP of new product development, care and identity products, at Experian Health of Franklin, TN.

Tell me about yourself and the company.

I’ve been with Experian for eight years. I oversee all of our new product development, the processes, the teams, as well as our identity and care management portfolio. Our Experian Health business is represented by the areas of revenue cycle management, identity management, care management, and analytics. We started in the market serving a group of providers.

What are the chances of the US implementing a unique patient identifier?

Now more than ever, there’s an openness to consider a national patient identifier, especially as topics of interoperability are getting more and more advanced through things like TEFCA. There’s a new acknowledgement within the public sector, the private sector, and the healthcare industry as a whole that a lot of the things that we want to achieve — in terms of true interoperability and improvement of care for patients and care coordination – all foundationally stem from having a national patient identifier in place.

I don’t have a crystal ball to predict whether that time will be tomorrow, next week, or a year or two years from now. But I do think that there’s been a significant shift and an openness, to where we are closer now than we ever have been to getting to a point to embrace the national patient identifier.

How would that change the company’s business?

I don’t see a large pivot. Our position is that there isn’t one key-holder to this identifier. It’s more likely and more beneficial that it’s a handful of vendors, of organizations, working together to provide it. 

We collaborate with vendors across many other lines of business. Our core business is as a credit bureau. If you look at that model, Equifax, TransUnion, and Experian work together, collaborate, and share information as it pertains to individual’s credit to ensure that the information is the most accurate when going out to consumers.

For us in a healthcare setting, do we provide identity services? For sure. Would we be open and accepting to collaborate with other key leaders within the industry to make this something that could truly help transform the healthcare industry? 100%. There’s precedent that has been set across multiple aspects of our business. That credit example is just one of many.

Online services often ask people to verify their identity by choosing their previous address or a car they used to drive from a list of choices, something that they know that others would not. How is that being used in healthcare versus just taking a patient’s driver license or insurance card?

That’s a service that Experian Health has been providing to the healthcare industry for several years. We work with a lot of the patient portal systems and are integrated directly with them. We can help provide the confidence to our healthcare clients that the patient is who they say they are, before you then open up access to all of their personal health information that’s highly sensitive. 

That’s something that we have carried over. Banks and financial institutions probably paved the way and were pioneers of setting that precedent. Healthcare is adopting that, as patient information is no longer on paper and it’s all electronic records. Access to that information needs to be protected and treated with the highest degree of security and sensitivity.

Surveys have shown that consumers, wisely or not, are willing to share their private information with companies that give them something in return. How will that play out in healthcare?

Even speaking for myself as a consumer, there’s a general frustration that we all feel when we say, “I can’t access all of my health information, my historical information, anywhere.” Unlike when I go online to look at my credit card statement and I can see all the transactions and I can look across multiple credit cards. The history, credits, and debits are all there.

It is absurd in healthcare that from a consumer perspective, if I wanted to do that today, I would have to individually reach out to find every doctor, every pharmacy, every lab test that I ever got, and manually go ask for that information. There’s a convenience where I would love to know that the care that I’m getting, the decisions that the doctor who’s standing in front of me is about to make on my health, are the best decisions.

The way for that doctor to make the best decisions is for me to provide the consent to say, you have access to that information, and there’s a way to pull that all together. The only way that that really happens is if you have an understanding of who I am as a patient across all of the different encounters that I’ve had. That stems by speaking the same common language, and the problem that we have today in healthcare is that we’re all speaking different languages. Everybody’s got a different way of identifying a patient and none of them interact. It’s like one health system speaking French, one speaking German, and another speaking Italian, all trying to talk to each other about a patient. It’s impossible.

Are health systems interested in using outside consumer information for patient engagement, marketing, or other communication that doesn’t involve only what the EHR contains?

Some are, but there are clear lines of distinction. This is where the patient plays a role in what information is being shared and for what purposes. There’s that clinical aspect of saying, I just want to be able to provide the history of my health so that that doctor has seen every lab result, every test, every procedure in their hands.

There is another element where, like in many other facets of our lives, we like the customization of the ads that are being sent to us, the coupons that are targeted to services that we enjoy, or the commercials. That transcends every other part of our life. In healthcare, there is an interest in saying, “Maybe there are pieces of who I am as an individual and the likes that I have. I’m OK with you having so that you can tailor my experience when I’m a patient visiting your portal or when I’m interacting with you as a healthcare system.”

That starts to get into things that could improve the patient experience and their overall engagement. A lot of topics stem around overall care management, care coordination, and how that patient is being treated and receiving care. There are broader socioeconomic data factors that can assist in that. But I draw a line of distinction between those. For a lot of consumers and patients, clinical information is different and feels different than your lifestyle, behavioral, and socioeconomic type information. Patients may want to choose to share those things differently for different purposes.

Some of the first uses of commercial consumer information I saw in health systems were as simple as verifying a patient’s identity via the address they provided or to determine their propensity to pay. Is it a big leap from there to using social determinants of health?

We talked about having a patient identifier. Studies done by ONC on patient matching show that having reference data, knowing more about a patient than what’s present within a healthcare system, can help you get a better match. It’s the same in social determinants of health. They say 80% of health outcomes are attributed to non-clinical factors. That means the socioeconomic factors that surround someone.

If you take a step back and say, what am I willing to give to get, it is like what you said about consumers. If a consumer knows that they could receive better care or have better care decisions made for them if they allow the caregivers or the healthcare organization to have a more complete picture of who they are as an individual, I don’t know who wouldn’t sign up for that.

Protections need to be in place to make sure that there isn’t abuse. Organizations like ours take it very seriously — the types of data, how that data is being used, and adhering to all of the regulations that are set forth. One of the things that we stand by very strongly is that we’re an original source compiler, which means all the data that comes into us, we have direct relationships with all those data furnishers. That allows us to ensure the integrity of that data, how it is intended to be used, and the regulations that are involved.

Others are buying data from somebody who buys data from somebody who buys data. The further downstream you get and all those different extensions, the higher the risk goes in terms of that data being used for the wrong purposes and for purposes that wouldn’t make a patient feel good.

What trends are you seeing in the increasing number of uninsured patients and high-deductible health plans that leave them paying more?

Patients have two pain issues – paying a larger percentage of the total and wanting visibility earlier. Sometimes it’s not the total of my bill that bothers me, but rather that I don’t have visibility before I get that bill in the mail. We do a lot of work with many of our clients to put patient estimates in the hands of consumers so that they are not surprised by what a particular procedure will cost or what their bill will look like. That goes a long way in helping them have a dialogue and a conversation with their healthcare provider to understand whether they have options or flexibility. 

That becomes critical, because it ties directly to the overall amount that the patient will ultimately be burdened with. There may be things that are optional within a patient’s care plan, there may be things that aren’t, or maybe there’s a drug that’s getting prescribed where there’s the option for a generic. Having that patient visibility into the cost up front allows that dialogue to happen, and maybe downstream to reduce that total burden and allow the patient to play an active role.

What is the expected outcome of Experian Health acquiring patient scheduling vendor MyHealthDirect?

What MyHealthDirect does is synergistic with what we do. We provide a lot of services that fall into the patient access realm. Bringing in the scheduling component to our suite of solutions, providing that ability to schedule a service, combining that with our matching and the correct identification of that patient, and then being able to facilitate the registration process, which starts to include running eligibility, looking at coverage, and providing those estimates. It’s really just continuing our breadth and advancing the more holistic solution of the patient access services that we can provide to our client base. 

All of this ties around our broader vision of of helping improve the care coordination for patients on behalf of our clients. It’s a natural fit and tie-in with many of the services that we provide today, but it also allows us go back to our clients with a solution that helps them manage that upfront interaction with a patient from the point of scheduling an appointment.

Do  you have any final thoughts?

We at Experian Health are excited about how we can help transform the healthcare industry, providing services and offerings to the market that are unique to our business. How we combine those, how we help solve challenging problems. One of the reasons I got into our healthcare space is that we have unique data and unique capabilities that, when hearing the challenges that our clients are facing, allow us to provide a differentiated solution. We’re excited about where we can help take the industry as we go forward.

HIStalk Interviews Jeremy Pierotti, CEO, Datica

Jeremy Pierotti is co-founder and CEO of Datica of Minneapolis, MN.

Tell me about yourself and the company.

I’ve been working in healthcare IT for about 20 years. I started off working at Allina Health in Minneapolis and ended up doing consulting. Then I co-founded Sansoro Health. Sansoro and Datica merged in June 2019, with the go-forward company name being Datica. We help healthcare move to the cloud by addressing compliance and data integration challenges.

What can the merged companies do more effectively than they could have done as separate organizations?

We knew that healthcare is moving to the cloud at an accelerating pace. As Travis Good and I started talking, we recognized that we had a complementary set of products, technologies, and team talent, and that if we put the companies together, we could help digital health engineering teams address the two challenges that they have to solve. Those are cloud compliance — which increasingly means meeting the HITRUST CSF requirements — and data integration, being able to exchange data bi-directionally between lots of different digital health applications. Electronic health records, but also all the different supporting systems that every health system runs.

How far along is healthcare in its seemingly inevitable move to the cloud?

It is toward the beginning of its journey, and it’s going to move fairly quickly. We’ve read lots of reports that show anywhere from 10 to 20% CAGR growth over the next five to seven years, and we’re experiencing that ourselves.

Like every other industry, healthcare is recognizing that what the cloud brings is not just running your software on somebody else’s computer in a data center that they manage, but providing access to a whole new set of tools for data analytics, supporting mobility, and integrating lots of types of data from lots of sources. You just can’t develop software with those features using an on-premise architecture. You are increasingly seeing large companies develop their new applications on a public cloud framework because it gives them the flexibility and the power of the toolset to leverage the capabilities of engineers and development teams all across the world.

How does the work of Cerner, Epic, and Meditech fit into a strategy of making their data available for use by cloud-based services?

They are moving deliberately and cautiously, understanding that they can’t make dramatic changes overnight. Their customers are big, complicated provider organizations for whom stability is enormously important. They are all looking for the right balance of making new capabilities available and taking advantage of cloud functionality that will give customers the features that they want, while at the same time, keeping their core systems stable. That means something a little bit different to each of those vendors, but they are all trying to find and strike that balance.

Would a move to the cloud change the exclusive relationship between a health system and their primary EHR vendor?

In the short term, I don’t think it changes anything significantly. I certainly don’t think it makes it more exclusive. In the long term, I think it makes it less exclusive.

I was listening to a podcast from Andreessen Horowitz, where Mark Andreessen was talking about how in Silicon Valley, you have this rich ecosystem of API-driven data exchange and whole companies that have been developed just to facilitate the development and management of APIs within industries. What we see in other industries will come to healthcare, too. When you have increasing adoption of cloud-based application development, you end up stitching those pieces together with API-driven data exchange. We’re seeing that same thing in healthcare as you look at the emergence of FHIR and other API toolsets for patient data exchange.

A move to the cloud by Cerner, for example, is not going to tie the hands of Cerner’s clients and make them any more dependent on Cerner. It is just part of the the slow, steady move toward health systems being able to choose from a variety of tools and integrate the tools that work for them best.

What is creating the demand for cloud-based services?

My colleague and our chief medical officer, Dave Levin — who used to be CMIO of at the Cleveland Clinic – says he spends all day working in healthcare and then he goes home to the 21st century. The reality is that it’s consumers. It’s our everyday experience with smart phones, tablets, and advanced software that we run on whatever device we choose and that allows us to move from one device to another almost seamlessly.

Those experiences that we who work in healthcare have every day in every other part of our lives make us realize that we need that same type of functionality when we’re delivering healthcare services to patients. When we’re managing populations of patients or health plan members, we need those same capabilities, those same toolsets.

To take the simplest of examples, there’s no reason that if I’ve been to the same doctor’s office six times in the last year, that I should have to fill out the same piece of paper on the same clipboard the seventh time. When when I walk into all sorts of other businesses, they know who I am. They have read my license plate or I’ve agreed to have my smartphone notify them when I walk in, so they know from the beacon  at the front door that I’ve arrived and they’re ready for me. It’s those kinds of experiences — the scalability, the mobility — that is driving healthcare organizations to create software with those same capabilities.

Will it be hard for healthcare IT vendors to move their systems to the cloud?

Vendors are looking to do that module by module. I don’t have deep insight into the Cerner-AWS announcement that came last month, but the way I understand it, Cerner is not saying that all of a sudden they’re going to move all of their clients who use Cerner Millennium onto AWS servers or AWS services. But they will be increasingly developing new software capabilities on the public cloud. On AWS specifically, for Cerner.

Going back to what I said earlier about the need for stability and reliability by providers and payers, but especially providers, our expectation is that you’ll see vendors developing their new software, their new modules, in the public cloud, taking advantage of those capabilities. They will work deliberately over time to figure out what makes sense in terms of potentially migrating their legacy products to a cloud infrastructure. I’m not sure I have any unique or special insight into that, but that’s the trend I’m seeing, health IT companies developing their new stuff in the cloud and migrating their customers who want those new features to that new platform.

Health IT vendors seem obligated to name-drop AI and analytics in their cloud announcements. What kind of learning curve will they and their cloud services vendor encounter as they modernize healthcare applications?

I wish I knew the answer to that. There clearly are some tremendously exciting applications of artificial intelligence and machine learning in healthcare. I’ve also read many pieces recently about the need to approach it carefully. Any time you’re going to train a machine to learn something, you need to make sure that you’re training it in the right way, otherwise you can create more problems than you’re solving.

But the cloud is a big part of that, because there are so many AI and ML services that are available through a public cloud infrastructure. AWS announced Comprehend, their natural language processing service, a couple of years ago. It allows users to train it and it comes at a competitive price point. That’s an example of how cloud service providers and application developers in AI and NL are looking to leverage the cloud — making those services available, allowing lots and lots and lots of engineers and creators to experiment with those services, test them, and determine what can have a real, positive impact on patient outcomes.

Big provider organizations are announcing their own cloud partnerships, such as Mayo Clinic and Google Cloud. How will those organizations work directly with cloud providers?

It speaks to the amount of data that providers are accumulating. They need to find ways to support the efficient storage and analysis of that data so that they can learn from it as quickly as possible and apply that to better operations and better patient care. It’s not surprising to me at all and I think we will see more of it. It’s understandable, because in other industries, you have big players, big companies that are on a daily basis using cloud platforms and the analytics capabilities of cloud platforms. To improve their products, to improve their customer service, and to improve their deployment of personnel.

Healthcare has the same needs and the same demands of end users to capture those capabilities without having to invest in standing up a new data center full of physical hosts and a big huge team of devops engineers, DBAs, and others to manage all of that traditional infrastructure. You’ve got all of that data and you need somewhere to quickly and efficiently store it and analyze it.

What impact do you expect to see from the federal government’s implementation of the interoperability and data blocking implications of the 21st Century Cures Act?

We’re waiting just like everybody. Our sense is that when the final rule is released, it will raise the floor, but it won’t necessarily raise the ceiling. We are looking to continue to push the ceiling with innovative solutions for integration.

We recognize that even when ONC and CMS release those new rules, it’s likely to be several years before they’re enforced. It’s going to take the vendors time to develop the technology and capabilities that those rules may require. We’re not waiting. We are working every day with health systems and innovative health IT companies to figure out how they can make the most of the data exchange capabilities that exist today.

The bottom line is that we’re eager to see what comes out. Industry discussion of those rules has been robust and the public itself is highly interested in it. Every person has a personal investment in being able to get access to and make portable their health information. So it’s fascinating, but we recognize that it will be years before anything is actually required and implemented. Our goal is to help our customers, providers, and payers take advantage of what they’re capable of right now.

Is the federal government at risk of oversimplifying the interoperability challenge in declaring mission accomplished just because the use of APIs and FHIR has widened?

As I listened to the debate over the last several months, and certainly after the draft rule was released, I was struck by how thoughtful and mature the discussion was across the board on these rules. There is a broad recognition within health IT that if this were easy, we would have solved it.

I’m not saying that it’s challenging mostly from a technology standpoint. It’s challenging mostly because there are lots of competing interests that have to be resolved, and they’re not necessarily easy to resolve. There are ways to do it, and our company and I personally have our own views on how to address some of those challenges. But it’s been a robust, mature discussion about how we balance the interests of different players, always keeping in mind that the goal here is the delivery of better patient care at lower cost and having better outcomes.

Do you have any final thoughts?

My colleagues and I are excited about the pace of innovation in health IT. If we weren’t, we would go find something else to do, since goodness knows the world has plenty of other problems to solve. I look forward going to work every day because of the opportunity to partner with people who feel emotionally compelled to bring positive change to something that impacts every single person — the delivery of quality healthcare.

HIStalk Interviews Steve Shihadeh, Founder, Get-to-Market Health

Steve Shihadeh is founder of Get-to-Market Health of Malvern, PA.

Tell me about yourself and the company.

I’m the founder of Get-to-Market Health, a consultancy that helps healthcare technology companies accelerate their growth and revenue. I got my start in healthcare IT as a sales trainee with Shared Medical Systems, and through a series of growth experiences, ended up being their leader for commercial activities. I then had that same role at Siemens Medical after they acquired SMS, at Microsoft Health Solutions Group, and then finally at Caradigm, a population health company.

About two years ago, I formed Get-to-Market Health. I have a passion about the business and what technology can do. I also have a strong belief that high-quality commercial activities are an important part of any successful healthcare technology business.

What advice do you give a startup or a company that is getting into healthcare for the first time?

A big part of what we do is help people understand the market, but equally, help them understand how the market looks at them. Healthcare buyers are different. We will often have clients who want to enter a new space and it’s just not the right fit, or they need to make some adjustments. Lead generation, building a pipeline, qualifying — all those things are important, but the most important thing is figuring out where their product fits.

What help do companies need in deciding what product to bring to market or how to get it in front of the right people?

The healthcare market is incredibly complicated, in a good way. It’s not just hospitals and doctors any more. Trying to figure out who the real buyer is, who has the authority to buy, who has the budget to buy, and how to present a product in its best light is an important issue for any company, but especially smaller companies that are trying to grow.

How should companies approach a market in which Cerner and Epic have become dominant and may become even more so as providers consolidate to create a customer base that has fewer, larger players?

It’s funny how the market has swung. It used to be that everything was interfaced and people bought best-of-breed. Now the pendulum has swung the other way, where a few large companies dominate the space. But I don’t think you can keep innovation or innovators down. 

A lot of the work we do is coaching and helping innovators figure out whether they should have a relationship with one of those big companies. If they are going to compete, how? And if they are going to get out of the way of the big vendors, how do they do that and still be successful? It’s a tricky landscape.

I think of the relationship between newspapers and companies like Facebook or Google that send them much of their traffic, but also take a lot of their revenue. How can companies figure out how to cooperate with those big EHR vendors while remaining aware that they also compete with them?

We see that every day. There is coopetition, where companies are OK that you compete or you partner. But I think vendors and also providers are trying to watch the way the landscape is moving because hospitals and health systems have that same issue around digital traffic as well. It’s a pretty interesting time to be in this space.

Will big health systems succeed in their for-profit efforts to create IT companies, invest in startups, or run accelerators and incubators?

That’s the multi-million dollar question. The organizations you’ve written about, which I know well, have invested hundreds of millions of dollars to incubate businesses. They are  becoming the investor. 

I understand the argument. To have a strategic investor behind a product like that is a big deal and will clearly help with other providers deciding to do business with them. 

It’s early to declare success. You can certainly point to some great examples – UPMC, Providence, and Northwell  have made some  good investments. It’s a clear trend because they aren’t able to make the margin they want on the core business and they have valuable intellectual property that they want to leverage.

How do companies that bring in new investment money meet the accompanying heightened expectations for growth?

It may be a little overused term, but it’s clearly an inflection point. The investor is betting on a multiple and a growth that wasn’t there before the investor showed up. Often the company that has taken an investment hasn’t really thought through how they’re going to make that growth happen. It is a point in time where the business evolves. Sometimes the players stay the same but just change what they’re doing, sometimes there are new players, sometimes there are new markets. But generally when an investor writes a big check, something’s going to happen.

What catch-up work do small companies need to do once they’ve hit a higher revenue level and have to start behaving like a bigger company?

We generally get called in when there’s a realization by the leadership team or the investor that they want to do more in terms of marketplace growth. What got them to that point isn’t going to get them ahead, so they want to try something different. It could be new markets. We have one client that is bringing in an AI machine learning platform from Europe to the US. People are taking products up into the enterprise space where they just used to work in community hospitals. It’s a realization that they want to do something different and they’d like an outside point of view as they do that.

How does a company formalize its sales process?

That stereotypical sales guy or sales gal from the past still exists, I guess, but they are a dying breed. One of the biggest changes I’ve seen in my career is how much more capable providers are getting as organizations and as buyers. They are pushing and demanding more from their salespeople than just buying lunch and overseeing a good demo. It’s clearly gotten better. Often we get called in to help them improve the deliverable that their sales team provides to the buyer.

How much of a company’s success is based on the skill, personality, or perseverance of a superstar salesperson whose traits can’t be easily replicated or obtained elsewhere?

It’s an interesting point. I suspect that the head of engineering has a few people he or she really relies on. The head of services has a few key people they rely on. I can’t argue against salespeople who are stars.

However, it’s more of the whole commercial mechanism —  how the company presents the product to the marketplace, how it prices it, how it creates product awareness, how it names and positions the product, and how it approaches buyers. You have to approach the CIO IT shop with your act together. You have to be able to answer the security questionnaire. You have to answer how it integrates with the EMR platform. You have to be pretty buttoned up in order to be successful today. It takes more than just a great salesperson. Although they are good to have and everybody wants them, it’s far bigger than that.

How do you advise companies to fit user surveys from companies like KLAS and Black Book into their marketing plan?

Really small companies don’t have to worry about KLAS, but they have other activities. Big companies have to invest in KLAS, Black Book, and various awards. Folks on the buying side really do use it. You may not be number one, but you had better not be off the list. It’s an acquired skill to be great at both delivering customer satisfaction and managing your relationships with those companies.

Do vendors call you because they haven’t done a good job at developing relationships with their existing customers?

One of the cool things we’ve been doing a fair amount of lately is running focus groups with clients and potential clients, to help them understand how they are perceived and how their product comes through. It gives them a safe zone to test ideas and get honest feedback. We facilitate that and help them hear what the potential buyers say.

Cerner hired KLAS to convene some of its big customers to tell the company how to improve its revenue cycle product and to ensure accountability as they did so. Will other companies do something similar instead of just talking to those customers themselves?

I’m not sure I fully understand the Cerner-KLAS thing. I was reading something about it this morning, in fact. One of the most important things a healthcare technology company can do is to get honest feedback about what’s working and what isn’t working. However you do it, I think it’s great. We seem to be getting more and more requests to help with it.

How do you see your business changing over the next few years?

It’s an exciting business. I have learned over the years that I don’t know as much as I think I know. It’s going to change in different ways. You look at some of the big companies that are spending money and hiring people and doing things and clearly there will be some shakeout from that. I hope they have the staying power and don’t get exhausted before they deliver some real products and capabilities. With the IPO activity and the buyouts that have happened, there will be more investor appetite for innovation. That guy or gal with a great idea won’t have any problem finding investors. It will be interesting to see where the products have an impact.

What goes through your mind when you walk the HIMSS exhibit hall?

I’m one of the people who actually enjoys going to HIMSS. Not because of the environment, but because it’s the business I’ve been in my whole career. I love the energy. You can clearly see who’s doing it right and who’s not doing it right. There’s a bunch to be learned from it. It’s a pretty amazing business, and a fun thing about the business I’m in now is that I can have a broader view of it. The roles I had before, in hindsight, were fairly narrow considering how wide the healthcare space really is and all the ways it is interconnected.

It’s clear that companies need to have their A-game for HIMSS or they shouldn’t go. We’ve helped several clients get ready for HIMSS and to do it right, but we’ve also counseled some clients not to go to HIMSS. They wouldn’t be heard above the noise. Awareness and creating client interest is a key opportunity for any company. They really have to pick their spots, whether it’s HIMSS or HLTH or any of the other regional or local shows. They have to have their act together.

Do you have any final thoughts?

You and I are fortunate to work in a business that’s evolving, growing, and consuming technology. It’s a business that all of us will depend on at some point in our lives. My view is, let’s make it better. We get to work with diverse business leaders to simplify the complexity and buying patterns of the healthcare technology market. That simplified buying process, with a clear understanding of what a product does or doesn’t do, is good for everybody. It’s win-win. No one, especially today’s providers, has time or money to waste. We think effectiveness and efficiency matter. That’s what gets us up and going every day.

HIStalk Interviews Ken Misch, President, Medhost

Ken Misch is president and CFO of Medhost of Franklin, TN.

Tell me about yourself and the company.

I began my career on a traditional finance and accounting track with Price Waterhouse in Cleveland in the late 1980s. After going back for my MBA in the early 1990s, I determined that I wanted to do something other than just auditing.

For the last 20 years, I’ve worked with smaller, growth-oriented, private equity-backed companies, either in the technology or the healthcare space. After a personal health issue surfaced about 15 years ago, I decided I wanted to spend the rest of my career in the healthcare industry. Obviously since Medhost is a healthcare IT company, I’m fortunate that I can combine my interest in tech with my passion for healthcare.

Medhost serves over 1,000 facilities. We provide these facilities with inpatient electronic health record systems, related implementation, revenue cycle, patient engagement, and hosting and other managed services as well.

How would you characterize the market that you serve?

Medhost mainly serves what we would consider to be the community or the rural healthcare market, which is a different market than the traditional tertiary care market. The urban academic, large research healthcare facilities that you find in very large cities, is a different space than the healthcare facilities that we’re serving, those out in rural America. Those facilities are really challenged. Maybe all of healthcare is challenged to some degree right now, but rural healthcare probably more than others. Rural America is shrinking, but there’s still a need for providing healthcare in those communities.

Al the IT vendors that serve the healthcare space have been challenged recently by the increased regulation that’s been coming out of DC with respect to Meaningful Use, interoperability, et cetera. All of us have had to spend and invest significant dollars in upgrading the systems. Not only to comply with increased regulation, but hopefully provide better optimization and efficiency for our customers.

How has the move of Epic and Cerner into smaller facilities as well as Meditech’s efforts to rejuvenate its business changed the dynamic?

Certainly competition is increasing and is getting more intense every day. Epic and Cerner have tried to provide offerings to come downstream. They’ve had different degrees of success with that. We’ve had customers that have tried both and have come back to Medhost. We’ve had customers that have been forced to do one or the other through a health system connection. We typically get feedback on how that’s going. 

We think we provide the right solution with the right level of functionality at the right price point for these community facilities.It’s hard for these larger systems to come downstream to de-feature those systems at a price point that makes sense for these community hospitals without cannibalizing their existing base. It’s challenging for those facilities to come downstream.

Meditech is is trying to do more with some of their current offerings, but they still have three basic platforms out there that they’re supporting. Their SaaS offering might add a fourth to that mix.

The marketplace is competitive. We recently announced a large win with Quorum Health. Quorum was spun out of CHS. They needed to find their own standalone platform. They went out in a competitive and rigorous bid process and eventually selected Medhost to be their system of the future.

Why do investor-owned health systems almost never choose Epic or Cerner when their large, non-profit counterparts almost always do?

You’re touching on the basic point — it’s about who you answer to. The investor-owned facilities or the investor-owned providers are answering to a group of shareholders and stakeholders. A lot of their systems and their choices are being run by processes that look at return on investment or cost.

It’s hard to justify a return on investment in any IT space in healthcare right now, but looking at it from a cost perspective, those other systems are at a price point that might not make sense for an investor-owned provider organization, whereas the not-for-profits don’t exactly have that same mission. They both have a mission of taking care of patients, but the investor-owned providers probably have a little bit more of a financial hurdle, as they need to answer to their investor group.

Do hospitals worry more about their image in buying Epic or Cerner because their large competitors did instead of looking hard at return on investment?

In the urban communities, the bigger metropolitan areas across the US, that might be more relevant than in some of the spaces that we’re serving. We’re serving communities that probably only have one hospital and the next hospital is 50, 75, 100, or 150 miles away. There isn’t a lot of true provider competition in the markets that we’re serving.

I could certainly see when facilities are competing for talent in a large city that they might want to recognize that physicians seem to have a preference for one or the other. Physicians don’t like really any system from everything I can read and gather. They have more of a tolerance than a preference. Perhaps they have a tolerance for one more than another, and perhaps they’re getting training on one versus another as they come out of med school. That could be a decision for competing hospitals.

We have a large, investor-owned company here in Nashville that we talk to on a regular basis. A lot of what they talk about is providing the physicians with some tools. They may not need to invest in the largest system that’s out there, that may be run by some of large health systems in the country. They may choose to go a different route, but provide their physicians with robust tools that they need to do their job. But the back-end engine might be something a little bit different.

What are small health systems that are too successful to close yet aren’t being considered for acquisition doing to remain in business?

It’s tough for them. They’re facing a lot of challenges. A lot of those facilities are going to be more heavily Medicare and Medicaid versus commercial reimbursement. That’s been getting squeezed. There is more competition and some of their higher-value procedures are being siphoned off by the urban centers. They’re still being forced to comply with the same regulations as the large facilities. They still have to chin the bar on all the various regulatory items with respect to Meaningful Use and the other items that have come out of DC.

We’re seeing innovation starting to happen with some of our customers. How can they innovate their business model? How can they come up with strategies to help their communities? How can they engage a little bit more with those communities to help offset some of those challenges? It’s tough in the rural space right now.

We are seeing rural aggregators that are popping up and buying some of these facilities. They’re not going to be as big as a CHS or even a Quorum, which has about 25 facilities currently, but they’re acquiring maybe a handful to 10-12 facilities. They are realizing they can run those with scale. They can leverage some of the infrastructure and spread that investment across numerous facilities. We’re seeing some degree of private equity money coming into that, although most of that is an individual investors or small partnerships.

What vendor service offerings can help small hospitals gain some level of scaling?

We’ve been investing heavily in our service offerings. It started with the IT and hosting side and other managed services. As facilities were forced to upgrade their IT platforms, they were staring at either investing in hardware to put on-premise and then they would have to have the resources, both from a human and a capital perspective, to support those and maintain those technology resources. These small facilities realized that they would prefer to have somebody else do that, so we started to invest heavily in our hosting services about six or seven years ago. Now we’ve built a world-class hosting operation here at Medhost. Most of our standalone facilities have now elected to move into our hosting environment. In fact, we’ve had some of our recent corporate customers make that same decision.

More recently, we’ve started to expand our revenue cycle services, our back office services, and business office services. The smaller rural aggregators want us to do that for them because they don’t have the skillset that they need in the facilities. They don’t want to make the investment at the corporate location, so they are outsourcing that to companies like Medhost.

Is technology, specifically maintaining IT infrastructure or supporting regional interoperability, a big driver of small hospitals affiliating with larger ones?

At times. But technology replacement is a disruptive activity. A lot of the facilities, especially the inpatient facilities, have a system that they’ve chosen here over the last three to five years, maybe even longer than that. They have  decided who their partner is going to be. They are looking for that partner to help optimize the system.

The government, with the 21st Century Cures Act and a lot of the regs that are coming out with respect to interoperability, are requiring vendors like Medhost and others to make their systems more open and to begin to share data. That it isn’t going to require significant investment on the facility side to just link up a similar system. The systems will be able to communicate with each other, so that they can get the largest return that they can on the existing investment that they’ve made.

Typically there has to be some type of triggering event for a customer to make a change with an EHR. Maybe they see an end-of-life coming at some point and they will need to make a different choice, so they may go out to bid. It could be through a merger and acquisition, where they’re becoming part of another entity that wants to consolidate on a single platform. It could be dissatisfaction. Certainly not all customers are always happy, and so they may just get fed up with the existing system. But it takes a lot to get to that point because of the disruption that rip-and-replace causes.

What is the demand for interoperability in your market?

We’re not seeing a lot of proactive demand. A lot of it will be reactive to what regulations comes out  to make sure that they can comply.

As these community facilities evolve, being able to capture some information from other providers, other avenues, and other platforms will be helpful for them. They’re going to have to evolve from the traditional episodic care center that they’ve been in the past. The community hospital of the past will certainly change into the future and will need to provide different kind of tools and services for the residents of that community. Opening up the systems to enable them to capture patient data — or resident data, let’s call it — from other systems will be helpful for them. In the mean time, what they’re thinking about right now is just, how are we going to be able to comply with this?

Do you have any final thoughts?

I mentioned that I had a personal health issue surface about 15 years ago. It presented again about three and a half years ago. I have an extreme case of coronary artery disease. After receiving all the best possible surgeries and treatments from the best possible physicians and facilities, my symptoms continued to present, even with the smallest exertion, so I was forced to look for alternatives and to think differently.

I was fortunate to get connected to thought leaders and researchers who suggested a significant lifestyle modification. It involved a complete overhaul of how I thought about nutrition, fitness, and stress management. After three years of adopting this lifestyle, I’m off all medications. I have no symptoms, and I have a vigorous daily exercise routine that serves as a stress test for me.

It might be a stretch, but I look at the challenges that are facing rural healthcare today in a similar fashion. Traditional strategies, business operations, and the wonderful clinicians at these facilities are being stressed every day. It will take innovation led by the residents and employers within these communities, in partnership with local civic and government leaders, to identify business models that can help these organizations not only survive, but hopefully to evolve and thrive in the future.

HIStalk Interviews Vince Ciotti, Retired HIS-torian

Vince Ciotti retired from a 50-year career in health IT in 2019. He documented the history of the industry’s companies, people, and trends over that time in his HIS-tory series. He can be reached at vciotti@hispros.com.

A reader of your HIS-tory emailed me to ask that I provide more information about you, which is why we are talking today. Describe your background.

I started in the business 50 years ago, in 1969. I was an English major at Temple University. I couldn’t get a job in any kind of English. There was an ad in the Philadelphia Inquirer for a programmer trainee that said, “see Clyde Hyde.” He  was one of the three founders of Shared Medical Systems. The rhyme caught my eye — Clyde Hyde.

I went up for an interview and Jim Macaleer, the president, was dumb enough to hire me. I didn’t know squat about hospitals, computers, or accounting. I learned it pretty quick and had 10 great years at SMS. Then I left them and went to about half a dozen smaller vendors. The first 15 years of my career were with vendors selling to hospitals, the usual job.

Then I got into consulting, first with Sheldon Dorenfest. I met a guy Bob Pagnotta up in New Jersey who’s a real HIS pro, one of the veterans in the industry. We started our own consulting company in 1989, HIS Professionals. It lasted for 30 years, which is probably a world record for consulting firms. Sadly, we just shut it down this year. Now I’m retired.

What will the future hold for health IT consulting firms?

When we started 30 years ago, there were small firms that gave advice to hospitals who were experts in HIT. Sheldon Dorenfest is a classic example. He started many vendors. He started telling hospitals how not to get snookered so bad. Other guys like Ron Johnson, a whole bunch of individual experts, were consultants. Today, I used the word in quotation marks because consulting firms are merely staffing firms. They’re gigantic, billion-dollar corporations that sell you people to do an implementation or to staff. They charge you roughly twice as much as the salary they pay and they make billions.

I’m a little out of touch with this stuff, but the four biggest, I think, are Computer Sciences Corporation, Xerox, Dell — which used to be NTT Data — and Leidos, which got the big Cerner DoD contract. They’re billion-dollar firms that just sell people. Their services are simply to do the implementation of Cerner, like they’re doing for the DoD. Whatever vendor you have, they’ll claim to have somebody that knows it. It’s probably a junior who you’re going to teach to become a more expert person, who they will then charge you more for in the next engagement.

Consulting has gone downhill in my mind. In the early days, it was wonderful. We gave hospitals good advice, saved them a ton negotiating contracts, and felt good at the end of the day to collect our few thousand dollars, not the few million dollars these guys collect today. A different world.

Is it inevitable that a company, regardless of its principles, will eventually get big enough to sell or perhaps to be managed differently?

Two-thirds of hospitals are not-for-profit, one third are for-profit. The non-for-profit ones just don’t know what life is like in a proprietary company. You start a tiny consulting firm, two or three guys, you barely make a few thousand each per month. You struggle to get into six figures. You start hiring a few people, then a few dozen people, you sell more and more, and you grow to hundreds of thousands of revenue, millions of revenue. The next thing is, let’s try to find a sucker to buy us and we’ll get $10 million for our pension fund.

It’s inevitable that a small firm — be it consulting, HIT, or whatever their business happens to be — grows. If they succeed, they’ll look for a buyer, because the original people are now getting kind of old and approaching retirement, like they have a huge stack of funds. So yeah, I’d say it is inevitable. Small consulting firms sadly grow, become giant consulting firms, and look only for the money, not for the good that they could do for their customers.

Your HIS-tory suggests that the same people repeat their success at making fortunes by selling companies that hire them as executives to do just that. What’s it like for the employees who have to just keep rowing down in the galley?

If you could see a bar graph of salaries, it’s mind-blowing. A typical vendor’s C-suite makes tens of millions a year, the managers make high six figures, and what the employees who do the bulk of the work get either in the five figures or just about $100,000. It’s a staggering variance and proportion of income from the C-suite to middle management down to the rank and file.

Where it’s nicest is the tiny startup firms. I was so lucky. SMS was almost a family, just wonderful people. They really gave a damn about their customers. Made sure they delivered the product. The first five to 10 years were just glorious. Then slowly they went public, became a giant, billion-dollar company, and those standards changed. It was purely the money. How can we cut costs and increase income? I bet that’s the truth of almost any company, be it a vendor, consulting firm, or even a for-profit hospital.

How has it changed as hospitals are seeing dollar signs in innovation and startups?

Not much. Every small firm that started way back then had the intention of making money. The successful ones did and got bought up, or bought up others, and eventually sold out themselves for even larger sums. I don’t think that has changed. That’s part of capitalism. I don’t mean to be critical. Believe me, I’m not a communist. I hated communism and Gorbachev is gone. But capitalism has its flaws, too. If making money is the only goal of everybody on earth, it’s a pretty ugly society. It’s the small firms that really care. That family kind of orientation that I really loved. They were the best years, the early years of a small firm.

Last time we talked, I threw out a few company names for you to react to. Let’s start alphabetically with Allscripts.

I get confused. They have bought so much stuff and have so many products. They’re a confusing company. Cerner, Epic, Meditech keep saying just what they are, just what they have. But Allscripts is a little more complicated. I wouldn’t be too optimistic about their long-term future compared to the monsters, Cerner and Epic. But they’re pretty good capitalists and I’m sure they’ll keep making money. I just don’t get too excited about their product line.

Cerner.

They’re the monster. My god, the VA and DoD will keep making billions for them for decades and it’s our tax money. Very sad.

In the original DoD contract, the majority of the money went to Leidos. Of the $8 billion contract, Leidos is going to get something like $7 billion and Cerner only $1 billion for licensee fees. For the VA, wow, the opposite. I think the last note on your site was something like $15 billion is the latest budget estimate for the first part of the VA to go on Cerner. Most of that money is going to go to Kansas City. So I’m very bullish on Cerner from an economic standpoint.

From a product standpoint, they still have a terribly weak revenue cycle. You seem to get a headline every couple of months of a hospital with a catastrophe. Great EMR, solid clinicals, but they still haven’t fixed what used to be called ProFit that’s now called Cerner Revenue Cycle. It still seems to be their weak link.

How will the company’s culture change now that Neal Patterson isn’t involved in running the company his way as the passionate founder?

Brent Shafer was an odd choice. You would think Zane Burke as president would have been the perfect person to be the CEO. He knew Neal real well, knew the culture and all that stuff. Then for some reason they go with this outside search and bring in an outsider. He’s going to be a pure revenue guy who will just want to make money. He doesn’t know much about hospitals or Cerner’s product line. That’s the classic capitalism problem, pure dollars. I don’t think they’ll sell many hospitals, but they’ll make a fortune out of the taxpayers on the DoD and the VA. They’ll stay at the top for a long time.

Epic.

Oh, Judy. Such a miracle. No sales and marketing. She’s so different. It’s just staggering that she’s made such a success and I think it’s going to continue. You know, the large hospital sales are all going to Epic. Many from Cerner, many from Allscripts as the old Siemens customers buy a new system.

Judy has a stunning future. Staggering success. It’s true hospital businesses, not taxpayers and DoD and VA. It’s really hospitals. She refuses to buy another vendor. Has had the same product now for almost 40 years, but the only vendor that has never acquired another vendor. I can think of no other that has been just their own system, period.

They have their weaknesses, too. They’re human. The kids, the young youngsters that they hire that don’t have much experience. The partner consulting firms that rip you off to give a lot of staffing for an Epic conversion. They have no homegrown ERP. Just like Cerner, you have to go buy another ERP and build interfaces. But boy, overall Epic … if I were a large hospital, that’s where I’d go.

Meditech.

Neil Pappalardo gave Judy a lot of advice when she formed Epic. She has followed his rules, which was never acquire anything, just build your own product. In those days, Meditech hired their own people fairly young like Judy did. Built all their own products, no interfaced partners, and they’ve got a complete set of applications.

Meditech probably has the most comprehensive set of apps of any vendor out there. With Expanse, they finally came out with a physician practice system. The last piece they were missing was an integrated doctor piece. So I’m very bullish on Meditech. Their sales were slow for a couple of years. I think for four years in a row, their sales declined, their revenue declined. Last two years, its finally come up. So hats off to Ms. Waters. 

I’m fairly bullish on their future. It’s just, darn, there’s not a lot a hospitals that are going to change EMRs. They stick with what they have. They spent so much money on it, they’re reluctant to go to the board and ask for a couple of million dollars for a new system. It’s just hard to get sales.

How much weight do you give technology when you choose your own doctor or hospital?

None. I go for the personality of the doctor. Do you like the guy or the gal? Does she like you? Can you get along with them? Can you smile? Can you talk?

I’ve got a family physician here in Santa Fe who’s so good that I’ll fly here from Florida 2,000 miles just to see him if I’m sick and then fly back. The ones I have in Florida suck. I just can’t stand them. To me, for a doctor, it’s the human side, the personality. Can you talk and you trust them? Do you think they really care about you?

For the hospital side, I had no choice. You may remember that I had a grand mal seizure in January. It’s kind of ironic. After 50 years in hospital computers, I retire and I go to my doctor’s office for a checkup and I have a seizure and they put me in a hospital and stick a computer in me. I got a pacemaker inserted in me and it saved my life. I’d have probably died. Still don’t know the cause, some kind of micro-stroke, but the pacemaker has been a damn miracle. Doctor’s say the battery’s good for 14 years. I told him I may not be good for 14 years. I’m thrilled to have it and it’s working like a charm.

The technology for the patient, when it’s interfacing with you personally, is priceless. Boy, the advances are glorious. You know, my father or grandfather would have dead with this seizure, and I’ll probably get 10, maybe 15 more years. So I love technology on a personal standpoint. But as far as the hospital’s computer system, I couldn’t care less.

I went to UCLA Medical Center and they have Epic. It was phenomenal to be able to see my whole chart on the screen with the security code and all that stuff. That was nice. And if I go to other Epic hospitals, they’ll know all about me. But a fourth of hospitals are are Epic, a fourth are Cerner, a fourth are Meditech, and a fourth are CPSI. If you’re admitted because of an emergency, you have no choice. If I had the choice, I would probably go with Epic now that I’m on that with my UCLA record, but again, when there’s an emergency, you have no choice. You go where ambulance takes you.

How do you see the dynamic among health IT vendors, salespeople, and health system executives?

In the early days at SMS, I was an early education manager. I had to train the new installers, as we called them then. Today they’re consultants, I guess, but then they were IDs, installation directors. I had a two- or three-week class to go through every single report, every single profile option, every master file, every transaction, whew. Took two to three weeks to train them and then they could still go out and botch up their first install. Took a couple of installs before they knew what the heck they were doing.

We hired salesman at SMS and they spent one day walking around all the offices, saying hello, shaking hands. Who are you? What do you do? Oh, OK. Then boom, after one day, they were out there selling. They had no idea what they were selling. It doesn’t matter. Sales is commissions. If you sell a lot of systems, you make a lot of money and you get promoted and you become a big cheese. If you don’t sell any systems, you get fired. You’re going to go to another company and try again.

You don’t learn the product. You haven’t been an installer or a customer service rep. You haven’t worked with the system. You have no idea how the system works. What you know how to do is smile, be pleasant, buy lunch, buy dinner, shake hands, be charming, have people trust you, get them to sign the contract, and then run like hell because you’ve got to make some more sales. 

That hasn’t changed to this day and never will. It’s capitalism. There’s nothing wrong with it. It’s just what life is like. Think of a used car salesman. What does he or she know about the engine, the transmission, or the differential of a car you’re buying? They know that they want you to sign quick before the end of the day. It’s not immoral. It’s not nasty. It’s just the truth.

Hospital, it’s so sad, they just spend time talking to salesmen. Hospitals should ask to talk to their installer. Who’s going to put the system in? I want to see him or her, have them walk around my hospital and tell me what good or bad things are going to happen. No hospitals do that, but that would be the dream, to see your installers before you sign that contract. Salesmen again are not immoral. They’re not liars or nasty people. It’s just their job. The job of used car salesman is to get you to sign that contract and HIT is not much different.

What do you think about the recent health IT IPOs?

It’s part of capitalism. Initial public offering is inevitable. The reason you form a firm is to get that stock on the market. Get double, triple, quadruple and away you go.

I joined in SMS in 1969. I got the 200 shares that Jim Macaleer gave to every new employee. I went to my boss and said, what’s a share? He explained it to me, and I said, what’s it worth? He showed me that it said 1 cent per share, so my 200 shares were $2. I was going rip it up, but he said wait five years, you’ll  be very glad. Sure enough, we went public around 1975. I think it was $14 a share. The stock had split several times before then, so my 200 shares were now like 800 or 1,600 shares. I was suddenly a very rich man. That’s the goal of capitalism, money, and it’s going to be the future as well as the past. That’s the American way. Nothing wrong with it, nothing immoral, it’s just the truth, it’s what our economy does. Nothing but money.

The only time I’ve sensed that you were star-struck was when you visited Judy Faulkner at Epic’s campus as you described in your HIS-tory. What surprised you about that visit?

She’s a very humble person. I walked into the lobby. There’s nothing massive, it’s just a lobby. Usually what you get is that the executive secretary comes over, asks if you want coffee, takes you into some big, glamorous conference room, and then after five minutes — there’s always a delay — in comes the executive. Shakes your hand, has two or three assistants on either side of them because they don’t know all the answers to your questions you’re going to ask.

I walked into Epic. I’m sitting in the lobby, you know, handsome couch. I look in the bathroom over there. There’s only a toilet, there’s no urinal. It’s a very female-oriented company. It’s kind of cute. All of a sudden, across the lobby, here comes this lady walking towards me. I suddenly recognize that it’s Judy Faulkner. No executive secretary, no setting me up in a big conference room.

She walks over, shakes my hand, takes me into her fairly small office, sits down, and says, “What are you here for? What do you want to do?” She’s such an open, humble, honest person. If you went to visit Brent Shafer at Cerner, you would probably get 45 minutes of introductory talk from other people before he finally came in the room, with seven assistants to answer all your questions. Boy, she just sat down and talked and said such honest comments. It was amazing. So yeah, she’s unique in our industry. Very a wonderful lady.

The one sad thing about her and Epic is that she is the company. I think she’s as old as me, 74, 75, something like that. At some point… she won’t retire. She’s not that kind of person. Epic has been her life and she’s very proud of it. I don’t blame her. But at some point, she’s human. She’s going to die, she’s going to retire, she’s going to have a heart attack. Who knows? Her successor can be nothing as good as she is. The company cannot have as bright a future once Judy is gone. She is the company. The company is her.

Sort of like Cerner and Neal Patterson, maybe Meditech and Neil Pappalardo. Neal and Neil slowly started to give the power of the company to their subordinates. I think Judy still runs Epic completely. I just can’t see a replacement for her. She is the company, personally.

Who are your heroes of our industry?

The folks at SMS, just because it’s the company I knew. Jim Macaleer and Harvey Wilson were the two bosses. Jim was just an incredible guy. He could be a mean son of a gun at times. A real Theory X manager. He was tough, but then the other half of the time he was funny, he was charming, he was pleasant. He just died, I think it was last year, 18 months ago. I’m really sad that we had to lose him. Harvey’s still around and doing wonderfully well. He not only helped form SMS, he was the number two at SMS, but then he formed Eclipsys and sold out to Allscripts.

We’re having our SMS reunion in a few days, the 50th reunion of SMS. One hundred and fifty people are showing up in King of Prussia and Harvey’s giving an introductory speech. To me, that’s a wonderful life, to have such a success and so many people coming to see you again and such a family feeling.

I can’t think of too many others that I really respect, that is until you get to the current vendors, and Judy would be at the top of that one.

How has retirement been versus what you thought it would be like?

Well, that’s an interesting point, because frankly I’m bored to tears. I’ve always been into motorcycles, Honda motorcycles. I started as a kid and that’s become my full-time occupation. I have six of them. I just sold one. I used to have seven, one to ride every day. 

I literally do ride a motorcycle every day. I get home about 1:00 or 2:00 from lunch and then wonder, what the heck am I going to do? I usually take a nap on the couch and I’m bored to tears. So I’m looking into some hobbies, other hobbies, maybe learn the piano, some other stuff. I love to look your site every morning, five minutes to get an update on what’s going on. Still keep up with a lot of good old CIO friends and consulting friends and even some people from vendors and we get together often.

Retirement is a bit of a shock. I had no idea what I was going to do and I still don’t. I work one day a year. I teach a class at Brown University, in their MHA program. I’m going out there two weeks and I probably spend about a week updating my vendor review and present it to the students. I should say “students” in quotes because they are CFOs, CMOs, CNOs, very sharp people. I probably learn as much from them as I teach them. But that two-hour class is the only thing I do all year.

When you meet someone and they ask what you do, they expect you to describe your job as your primary identity. How do you introduce yourself now?

I’m usually on a motorcycle when I meet somebody. We start talking about Hondas. I don’t meet professional business people any more, but if I sit next to someone on an airplane who wants to know what I’ve done, I tell them that for 30 years, I was a hospital computer consultant, and then for 20 years, I used to work for vendors in hospital computers, and now I ride motorcycles. That kind of sums it up.

You’ve got to think ahead of retirement. I didn’t and I’m sorry for it. I didn’t have any plans at all and I’m struggling with it now. If I didn’t have the Hondas, I’d go crazy.

Do you feel any springtime pull toward the HIMSS conference?

I live down in Orlando right next to HIMSS. I used to go every year, and the thing got so big. I started to get totally bored to tears with 40,000 people in one hall and hundreds of vendor booths. At the booths, the few old guys or ladies I knew were just not there any more. Dozens of young sales reps. So no, I have lost my affection for HIMSS. When it was small and you knew everybody, it was wonderful. It was glorious. It was a family kind of thing. As it has grown to the gigantic size of today, I haven’t gone for the past two or three years.

When I presented there, that was a lot of fun. Thank you for having me to do that HIS-tory presentation there and dress in the wacko hippie suit. Got me into the whole HIS-tory file, those 120 episodes you ran on your website, but I had never presented at HIMSS. If they wanted me to present the HIS-tory thing again, I would do it. That I love. But to just walk around the halls and meet all those green salesmen who I never knew and they never knew me bores me to tears. I can’t stand it.

Not many people seem to be interested in health IT’s past. How would you convince someone to read your HIS-tory, either now or 25 years from now?

It’s the same as reading the history of the human race, history of America, history of Europe, history of homo sapiens. You can only learn from the past. You can’t learn from the future. It’s not here yet. The mistakes made in the past will be made in the future unless you learn from them and change them. It’s such a priceless thing.

I just bought a book on the history of warfare. I’m a reader, I own thousands of books. And the first page has an incredible statistic. Of the past 5,000 years of human history, roughly back to 3000 BC, only in about 300 years have we not had a war. If you haven’t read history and learned that, you’re not going to appreciate the risk that we’re going into World War III with nuclear weapons and all this horrible strife between small countries around the world. You have to learn from the past to be able to avoid those mistakes in the future.

In HIT, what vendors did back in the sixties, seventies, and eighties, they’re doing today in the 2010s into the 2020s. Only when you read it and learn what they’ve done will you know what they’re going to do in the future and how you can avoid it. You avoid being a victim and help your hospital get a little bit of its money’s worth. I think it’s priceless in any industry — automobiles, transportation, education, automation, you name it. You learn from the past to do better in the future. If you just go into the future blind, you’re going to make the same mistakes.

What will your epitaph say?

If I could be remembered for anything, it would probably be my HIS-tory files, which I thank you for posting over such a long time, two and a half years. I hope some of the future CIOs read them and learn from them. I hope that’s what they remember me by, the guy that warned them about not repeating these mistakes of the past.

HIStalk Interviews David L. Meyers, MD, Emergency Physician Leader

David L. Meyers, MD is retired from a long career in clinical medicine. He continues to consult, serves as a board member of the Society to Improve Diagnosis in Medicine, and is pursuing a master’s degree in bioethics at the Johns Hopkins Bloomberg School of Public Health.

Tell me about yourself.

I’m an emergency physician. I trained at Cook County Hospital in internal medicine, before there was a board exam. Emergency medicine was emerging as a specialty. I stayed in Chicago and went right into emergency medicine practice instead of doing internal medicine. I dabbled a little bit in internal medicine at Northwestern and did some research, but basically I’ve been an ER doc all my life.

I ran an ER in Chicago for about 20 years and then came to Baltimore to run an ER here at Sinai Hospital . After a few years, we brought in EmCare, a private medical management company, to staff the place and hire the docs. I went to work for them and did a bunch of executive-type things over the next 10 years, including running a malpractice insurance company operation, their risk management claims management. It was a publicly traded company at the time and still is.

I continued to practice clinically once a week, commuting to Dallas for five years and coming back here after my Friday night in the ER so I could keep my hands in the nitty gritty of what’s really going on in the field. 

I retired a few years ago and decided I wanted to pursue medical ethics in more depth. I had been on ethics committees all my clinical career and found it really interesting and challenging with what is going on in healthcare. I’m not sure what I’m going to do with it. I have some ideas about the discrepancy between business ethics and bioethics. There may be some opportunity to blend those kinds of things to have a more humane and better healthcare system.

How extensive is misdiagnosis and how do you assess the market for artificial intelligence to improve it?

Huge and huge. Misdiagnosis or diagnostic errors make up at least 50% of all harm-related medical errors. Most of the reliable information is based on claims data from medical malpractice, which is not a great marker for total number of diagnostic errors. But the ones that people are really concerned about are those that cause harm – significant disability, loss of limb, loss of the ability to work, and even death. Diagnostic errors are the most frequent cause of those high-harm results.

A recent study published out of by Hopkins David Newman-Toker and his associates looked at what turned out to be the Big Three conditions. They went to a big insurance database called CRICO, which insures about 400 hospitals and healthcare systems around the country, including Harvard and Hopkins and a bunch of other very prestigious academic medical centers. They looked at the claims data from this database to identify those conditions that were most often associated with high harm, that is, these disabilities and death. The categories turned out to be infections, of which sepsis, certain other paraspinal abscesses, and four or five other things were very prominent;  vascular conditions, mostly around strokes and heart attacks and similar kinds of conditions; and cancer. They called these the Big Three that are responsible for most of the significant harm-related categories.

This study is one of the best to flesh out how big of a problem this is. The total number of serious harm-related incidents ranges from 40,000 to up to 1 million, depending on how the analysis is done and what the source database is. It comes down to that a diagnostic error is associated with 5-7% of all patient encounters.There are hundreds of millions of diagnostic encounters every year. You’re talking about a large number of errors and then correspondingly large number of serious errors resulting in harm.

Is that misdiagnosis or failure to diagnose?

It’s a combination. It uses a definition of diagnostic error that came out of the Institute of Medicine, now called the National Academy of Medicine, that published a big monograph study on diagnostic errors in 2015. Their “To Err is Human” in 1999 said that the biggest problem is medication errors. That was the illusion of what was significant. While there were lots and lots of medication errors, they weren’t so much the cause of significant, harmful outcomes. Only in the last five or six years after this study was published was there an acknowledgement that the biggest harm-related cause was on the diagnostic side of things.

Is medical imaging analysis the most potentially useful deployment of AI in the care setting?

It is possible for an intelligent machine to look at millions and even billions of images in a very short period of time and then learn, through these neural networks and other mechanisms, how to recognize what’s a man, what’s a woman, what’s a cat. Companies have produced X-ray assistive artificial intelligence devices that can look at millions of images and be more accurate than radiologists. Sinai just got one of these artificial intelligence image analysis tools for looking at brain scans for hemorrhages. The studies show that Aidoc performs better than a panel of radiologists.

That’s not just in radiology, but in dermatology and other kinds of image recognition things. That’s where the first successes have been shown to be pretty good and where the greatest potential is right now, Then it could be expanded it to other areas where the appearance of something tells you what’s going on, such as diagnosing depression by looking at facial images.

In the the study of diagnosis, most errors occurred in the realm of cognition and cognitive errors — not considering a condition as the cause of the symptoms, not ordering the appropriate tests, or making decisions along the way that weren’t so obviously putting together a whole lot of data and saying, here’s the diagnosis.

At some point, I suppose we’ll have a Tricorder where we just put a bunch of information in and pass the patient through a CT scan type thing and it will come out with the diagnosis. But that is pretty far in the future. The thing now is, how are we going to help doctors be smarter cognitive players in the diagnostic process and assist them? 

Consider prompts and reminders. Can Epic, Cerner, or some of these other EHRs develop ways that the electronic record can say, “This is a middle-aged male with back pain who’s got hypertension and had pain radiating to his leg.” Then set up a tool that says, “This could be a patient with a significant risk, maybe 5% or more, of a leaking aortic aneurism.” Put that prompt on the screen to the doc to say, “Have you considered a AAA rupture or leakage in this patient?” 

We’re not there yet. They’re apparently not able to do that, although it seems that the technology is there. There’s a diagnosis tool called Isabel. It’s free on the Internet. You put in your symptoms and it will generate a differential diagnosis list, the things that ought to be considered as possible causes of the symptoms you’re having. 

The potential is there, but so far it hasn’t really been adequately exploited. Most of the effort seems to be looking at these deep learning things, where neural networks are used to teach machines how to recognize a mass on an x-ray or depression in a face or something like that.

Some of that is available now in the form of evidence-based clinical decision support, but doctors don’t always embrace it. What dynamic will need to be overcome to get doctors to see AI as a partner rather than a threat?

There’s still a lot of resistance. Physicians may be skeptical about how big of a problem diagnostic errors are. A lot of studies have shown that doctors are confident about their diagnoses even when they’re wrong. There’s this attitude that, “Maybe there’s a big problem, but I am not one of those problematic people. I’m above average.” Everybody thinks they’re above average in their diagnostic capabilities.The literature is telling us that it ain’t so, but getting doctors to believe it is another whole thing.

Then there’s the cost of all these AI-type things. EHRs themselves, as bad as they are, are a huge expense for hospitals. They’re already struggling to make theme cost-effective. Adding additional bells and whistles that the doctors may not even accept is a risky kind of proposition.

What about the ethical issues of AI in healthcare that have received widespread coverage lately?

Artificial intelligence tools are created by humans who have their own biases. There is recognition that those biases can be built into the tools of artificial intelligence. They aren’t yet totally objective. Health equity issues that plague humans and our biases may be built into those systems. Not consciously, but because it comes from human creation, it’s automatically saddled with human biases, even though they can be minimized. We haven’t figured out how to eliminate them yet.

What technologies hold the most promise for improving outcomes or cost?

In the long run, artificial intelligence is probably the key to better care and lower costs. But with regard to timeframe, I’m skeptical about whether we’ll be doing this on earth or doing it on Mars. It will be decades in the making for this to come to a point where it’s having such an impact, although imaging analysis has a very reasonable timeframe in the near future to make a difference. If we can have better imaging analysis and diagnosis, that will contribute to a significant reduction in harm and lower the cost of care.

There are predictive analytics systems that look at masses of records, collecting them and putting them into categories for making predictions. The Rothman Index, which I think is mostly done manually by nurses entering information into the patient record multiple times per day, looks at those inputs and recognizes patients who are potentially at risk. It gives an early warning to the staff using those 20 or 30 parameters from the nursing notes, vital signs, and other electronically collected stuff. It says, “This patient is going to need a rapid response intervention in the near future unless you intervene with some technique now.”

By aggregating millions of patient records, I think we’ll be able to predict who isn’t taking their medicines, using an Apple Watch type thing or something like that. We could say, “The patient isn’t taking their medicines. The patient gained weight. We have to send somebody out there to intervene. Maybe their heart failure is getting worse.”

That is where the potential for improving the care and reducing the cost is going to be. These predictive analytic tools, collecting data in the background and telling the providers, “Pay more attention to this guy. He seems to be on the verge of deteriorating.”

HIStalk Interviews Steven Davidson, MD, Retired CMIO

Steve Davidson, MD, MBA is retired as an emergency physician and CMIO of Maimonides Medical Center in Brooklyn, NY and provides consulting services as EMedConcepts.

Tell me about yourself.

I was born in Philadelphia. My dad was an internist-gastroenterologist, doing endoscopies back in the era of rigid scopes. My grandfathers were home carpenters, so I grew up with the idea that you could use your brain and you could use your hands. I went to medical school because I had ambitions to be an academic. I discovered emergency medicine as a new field. I was impressed by David Wagner, who was one of the grandfathers of the field. He was a pediatric surgeon who worked in the ER so he could pay his kids’ tuition.

Since it was a new field and there were fewer people clambering around on the ladder, I thought I might get to the top quicker. I never really made it to the top, but did OK. As one of the earliest trainees, I got involved in academic emergency medicine and was a tenured full professor. I went to Wharton, got an MBA, and managed to land a really nifty job in Brooklyn, working for a guy who was doing a turnaround on a hospital there, Maimonides Medical Center. 

He let me take the ER as an independent business unit. I ran the medical side and the business side of the ER. Everybody who worked in the ER worked for me, including nursing. If there were more than five people in a job title, they worked for me. I did that for 15 years, managed to piss off a few people, and got kicked upstairs to the CMIO gig. I discovered that my impatience and short attention span, which was an asset in the ER, was a contributor to a crash landing in the executive suite.

I went back to taking care of patients for a few years, sold my place in Brooklyn at the top of the market, and came back to Philly, where I had real connections beyond professional friends. I’ve spent the last 16 months renovating an old stone pile, a 100-year-old house, and working on Steve — going to the gym, eating right. I’ve gone to hear lots of live music. That’s enough.

Now that you’re somewhat of an outside observer of healthcare, what do you see?

If you’ve seen one ER, you’ve seen one ER. They are all different. I brought to that my experience with W. Edwards Deming and the idea of improvement processes, things like that.

Culture is an overwhelming force that is hard to overcome, and healthcare’s culture has been incredibly physician-centric. The nursing force was always there, but has gotten much stronger with the real administrative control that has gotten much, much stronger. It’s hard to see how, other than in small-scale improvement efforts, overall system improvement is going to happen without major legislative and financial flow change.

Your work in the ED was the ultimate episodic practice. Is it a marketing challenge to convince patients / consumers why they should value continuity of care when they are reasonably happy with the status quo other than price?

Middle-class folks who can afford the drop-in to the urgent care centers are eager to scratch that itch right away. In my experience in caring for the people who were not regularly doctored – for example, the folks who were on medical assistance in Brooklyn and had to make do with hospital clinics — would get very dejected when the internal medicine resident who had clinic once a week graduated after three years and was no longer their doctor.

I can’t tell you how many people I saw over my 15 years in the ER who would show up after not having been in the ER very much in the previous several years. They had been assigned to a new doc and clinic and they didn’t like that doc. Those people craved the continuity of care. My middle-class friends on Facebook, to all appearances, are glad for the networks of urgent care centers.

How should we apply social determinants of health to improve public health?

Many ERs, including where I used to work, have identified lists of frequent flyers. This goes back to the work of a guy at Cooper in Camden that was written up in the New Yorker, it might be 10 years ago now. He identified people who needed a new refrigerator, a new bed, or their roof repaired. Social determinants of health.

What’s happening in a place like Maimonides Medical Center is that the patients who were constantly in the emergency department, they are trying to get at the contributors to these visits. They get social work and community organizations engaged. At Maimonides – I’m not hawking what they’re doing as anything special because I know other places are doing it, I’m just telling you about the place where I know a little something — put together this community health network. They have integrated behavioral health with primary care for this patient population, for the broader group of patients with any serious behavioral health issues. It’s apparently having some impact on the frequency of utilization of the emergency department by individuals identified within this population.

As someone who ran medical services for a big-city fire department, how well have we integrated 911 services, pre-hospital care, and related technology into hospital practices?

There was a time when EMS developed as a medical service. If you go way back, ambulances were a secondary function of hearses. If you move a little bit past that, Frank Pantridge created heart ambulances in Belfast, Northern Ireland to save “hearts too good to die” with a defibrillator. Trauma surgeon David Boyd recognized that trauma care in Vietnam was better than it was for a motor vehicle crash victims.

Pre-hospital care developed as a medical service. Over the years, fire departments increasingly engaged it, initially for their own purposes to provide services to their own people who got injured at scenes. Over the years, as the number of structure fires began diminishing — both because older structures had burned out and because of better fire prevention practices — fire chiefs needed to maintain a reason for a handle on the public purse. Since they already had ambulance services for their own folks, they increasingly moved into EMS. Ultimately, what we’ve decided as a country by and large is that EMS pre-hospital care mostly resides in paid fire departments, at least in the urban and inner suburban areas.

Even as that was happening, Joe Ryan in Pinellas, Florida and others like him identified that a large number of people were calling for care. They were worried well or had something small and self-limiting that could be dealt with on the scene. In Brooklyn’s Orthodox Jewish community, you have Hatzolah, an all-male volunteer ambulance service that raises funds, does not bill, and hence has no requirement to transport. Without transport in EMS, nobody pays. You get paid for the transport, not for the care. Hatzolah is an example of doing this right within the community — responding to people’s needs, offering help at their bedside or in their home or workplace, and not necessarily transporting.

Emergency medical dispatch, created by Jeff Clawson, MD, is a discipline that has developed data-driven protocols to give telephone advice prior to arrival and to help select the requirements for urgency of response. The fire departments are overwhelmed and budgets everywhere are under such stress that they are interested in interventions that avoid transport and divert callers / patients into other means of care. That’s probably a good thing if it’s being done correctly. Joe Ryan, who now is in Reno, got money from CMS several years ago to look at an expanded role for paramedics to offer care in the community. I don’t know whether he was able to move forward with that based on issues with the local ambulance providers.

Doctors and nurses, by and large, have a charitable and helping impulse. With the public safety mindset — firefighters among them, who are rightly celebrated for running into the danger when everybody else is running away — there remains some question in my mind as to how suited the fire department is to be doing this work. But clearly fire chief leadership across the country has taken up this role throughout and is doing the best they can with it.

Jim Page was a fire chief, founder of the Journal of Emergency Medical Services, and a big booster of EMS on the fire side in California. Mr. Page has been dead for a decade or so, but there was a point at which he quite publicly said that doctors in EMS were bossy nuisances. To some degree, that’s part of the environment I worked in and why I decided to move on from the EMS leadership roles I’d had.

We first exchanged emails about the extent of misdiagnosis and how machine learning and artificial intelligence might have a role. As a doctor, how much value would you receive from technology helping you arrive at a diagnosis?

In the dim, dark past, I was a clinician working with John Clark, a surgeon. He was able to show that a junior resident using his software solution, running on an old Mac, was more accurate in diagnosing appendicitis than the most experienced surgeons by themselves. There was a period of time where John’s software was used on the orbiting space station. That was before we did a lot of bedside ultrasound and CT scanning of the abdomen. I’m telling you this story just to preface my response that in medicine, certainly emergency medicine, we are learning about our cognitive errors in reaching decisions for patients, including diagnostic decisions.

The heuristic is that you know what you know, and if you don’t think of something, it doesn’t end up on your differential diagnosis. If it’s not something you see very often, you may not think of it. Systematic ways of prompting consideration of reasonable possibilities — and who the hell knows what “reasonable” is? —  can be of value.

I just saw a paper pointing to the three areas of most diagnostic error harm – vascular events, infections, and cancer. These are big categories, even in the emergency department. Patients have cancer that hasn’t yet been diagnosed or they’ve had previously diagnosed and treated cancers and present with a new set of symptoms. It’s easy to think in terms of the statistical probabilities rather than considering the possibility of other cancer stuff.

What advice would you offer to someone looking forward to retiring and not having to go to work every day?

I’m no great fan of Arthur Brooks, who just announced that he’s retiring as executive director of the American Enterprise Institute, but he had a spectacular essay in the Atlantic called “Your Professional Decline Is Coming (Much) Sooner Than You Think.” It basically says that you are already past the peak of your career. You just don’t know it.

He writes very broadly in terms of how you might think of the rest of your life. I have found it thought-provoking and well worth the read. For me, I am a reader. I am a curious person. I’m a big-time lover of acoustic music – bluegrass, old-timey Irish music, and all the mash-ups of that.

You must be more than your career. I’m extraordinarily fortunate that my folks introduced me to music while I was young. They didn’t give me a hard time when they found me reading the Encyclopedia Britannica under the bedclothes by flashlight in the middle of the night.

People are where it’s at. The residency that I was part of at Hahnemann Hospital is gone and the hospital is closing down. Before that, Medical College of Pennsylvania, where I spent 20 years. That’s gone, absorbed into Drexel. Places disappear, places change.

I’ll just close with one last thing. A man very close to me — we’ve been friends since we were 18 — had a terrible fall last week. He was horribly injured and is in an ICU of a big trauma center. I got to his bedside about 20 hours after he got to the hospital, but I got help by reaching out to the broader emergency medicine community. I was connected to the doctor who first cared for him when he hit the ER. That doctor was two degrees of separation from me, and I was connected to that doctor within about two to three hours of calling out for help to my network.

It’s people, it’s people, it’s people. Whatever you do in retirement, stay connected to people.

HIStalk Interviews Peter Smith, CEO, Impact Advisors

Peter Smith is CEO and co-founder of Impact Advisors of Naperville, IL.

Tell me about yourself and the company.

I’m the CEO and one of the two co-founders of Impact Advisors. We are a consultancy that is dedicated to healthcare and we are a technology-enabled process improvement firm. We focus on what your readers would consider to be the HIT market, as well as helping our clients optimize their processes across the organization.

Our clients are pretty much all flavors of healthcare providers — IDNs, all kinds of hospitals, physician clinics, and almost any entity in healthcare. We also do a little health plan work as well, but predominantly it’s the provider-based segment that we work in.

It seems like most big health systems are playing around with digital health, innovation projects, and consumer-focused initiatives, to the point that they’re creating C-level positions to oversee them. Is this a fad or are health systems really changing the way they do business in response to changing demand?

It’s a combination of both. We’re obviously seeing a shift in healthcare. Whether it’s the concept of moving towards value-based care or more consumer-directed care, there’s a lot of dynamics that are being backed up in terms of reimbursement models. We’re not there yet. I just gave another interview talking about organizations that have one foot in a fee-for-service world versus the new world. I fully recognize that we’re going to be in that state for a while.

But clearly we’re moving there, and that’s driving a lot of organizations to think about some of the things you just mentioned — digital health, patient and consumer access, how to create a digital experience for not only patients, but families. All of that’s coming into play. Organizations are optimizing the existing environment, but also thinking about how to start building technology services and processes in the new world in preparation for a shifting environment.

To answer your question, I think a good organization will not only retain what they’re doing and optimize it, but also think very diligently about how they move forward with things like digital health or optimizing their a future environment.

Health system competition is no longer just the other hospital across town, it’s regional and soon-to-be national health systems, drugstore chains, insurance companies, and research organizations that are coming in late to the health IT party. Do health systems have the level of expertise, both corporately and in the CIO office, to keep up with the new technology demands?

You’ve hit on a couple of major trends. Obviously many organizations are moving towards scale. Five and $10 billion a year organizations are becoming $20 billion because they need to get to a certain scale. Certainly from a managed care standpoint, to drive economies within the managed care world or the impending value- based care world.

I have a little empathy for folks who are running hospital systems right now. It is not an easy world. They’re getting hit from all sides as they have to aggregate and get scale to be competitive in a new marketplace. They have to create relationships with patients in a different way that I just described, and all the investment that’s associated with that.

Another major driver is what’s being carved out of their systems. Profitable services are being carved out by for-profit companies. If you’re running a large hospital system, you’re getting hit competitively from all angles. That’s a very tough place to be.

You asked particularly about leadership. You’re seeing some very progressive leaders in this space. Those are the ones who are going to be successful, who are thinking about their business models in a new and different way and maybe even challenging some of the traditional ways.

As health systems scale into multi-billion dollar revenue, will the people they choose to lead IT and innovation increasingly be hired from outside the industry?

You’ll start to certainly see that. But there’s a premium in terms of understanding healthcare and understanding healthcare technology. You’ll see entrants, some of them very good, from outside of the industry, but they will have a steep learning curve.

I don’t believe you’ll see a major tipping point where organizations are actively bringing people in from the outside of healthcare. But I do think that condition will exist, and in some cases, it will be very successful, while in others, maybe not. It will be predicated on the individual and what previous experiences they have had.

Providence St. Joe’s is in a geographic area where they have a lot of talent around them  — Microsoft, Google, and Amazon — but that access to talent might not exist in places in Nebraska. If you’re in those markets, you exploit the best talent you can. If they also come with healthcare experience, that’s an absolute bonus.

How does having larger but fewer healthcare systems as customers change your business?

We think about that every day. We recognize that in some parts of our business, we have to get to scale. Certainly in some of our implementation practices, we need to ramp up our recruiting to service clients in a much larger way than they have traditionally. When we were working for the mid-sized market — the $1 billion to $3 billion organizations that have IS departments of 100 people — we could serve as the whole team. Now we look at a scaling, not only of our internal resources, but how to partner with others to be a full-service providers.

Providence St. Joseph Health, Mercy, and other big health systems have blurred the line between provider and vendor, with the former hoping to create a billion-dollar annual revenue organization. How do you see that playing out?

I’m very interested in seeing it. I’ll even add a little twist to that, the Optum deal with John Muir that was announced about two weeks ago, a major platform play and potentially extending that platform beyond. This is not a new concept. Many IDNs have created some form of managed services organization over the decades. Some have been successful and some have not.

It’s going to be about leadership, client relationship management, and about how they execute. I think the concept is sound. How do you aggregate services in a better, higher-quality way at a lower price point? Those are sound objectives and the industry needs that. How they execute over the next year or two is going to be critical.

Providence St Joe’s is fascinating. Just in full disclosure, we’re doing work there, so we know a little bit about their designs on Community Connect and beyond. But these models can absolutely be successful. They will probably first be successful on a regional basis and they’ll use those as proof points and qualifications to possible extend beyond.

How do you see the movement toward cloud computing as Cerner announces a deal with Amazon Web Services? Will we see a lot more results of vendors moving to cloud services offered by Amazon, Google, and Microsoft?

We’re just on the tip of it right. In healthcare, most IT processing is on premise. You’re seeing companies that are moving to the cloud very quickly and having a lot of success.

Cerner is probably the best example of having success in their application management services model over the last decade. Epic is now having a lot of success. Workday in the ERP space is using that as a competitive differentiator and people are gravitating towards it because it implies a level of standardization. It makes your maintenance more predictable, your expenses more predictable, and you’re building a support environment that is homogeneous and high quality.

Health systems are increasingly spinning off startups and running incubators and accelerators. How will that change as they start to see the results of their early efforts?

It will absolutely continue. There’s a lot of variability in how people think about, develop, define, and execute innovation. On one hand, it could be just like a tech transfer function, to allow some form of liquidity for inventions or ideas that are coming out of their medical staff. That’s a very traditional look. In other areas, these guys are running shark tanks and small venture capital firms.

You’re seeing this incredible continuum of how they think about innovation and investment and how they want to monetize or get the ROI out of it. I preface my comments that it remains to be seen whether there will be a a common approach in our industry to innovation across the landscape. You’ll see some variability in how organizations think about it, but it will continue to be important part.

We do a lot of digital health planning and it always ends in a plan that is doing a couple of things. It’s leveraging technology that’s already exists in place, foundational systems like the EHR. It’s also buying or developing a series of solutions that might come out of your own innovation area, or you may buy them commercially, and building an ecosystem of digital health. As we get more mature in that space, those solutions will get rationalized and you’ll have greater platform players. But right now, successful organizations are moving in this continuum of knowing that they have to solution a digital world with many different partners and providers.

Are the three significant health system EHR vendors supporting that innovation by opening up their systems to other companies? Is interoperability more of a technical problem or a business problem?

In our business, we joke that the most difficult thing is integration between systems. Why it’s difficult is a combination of factors. One is the competitive factor, where a lot of healthcare organizations don’t want to share with their neighbor across the street because of the competitive advantage. It could also be a cultural, political, or technology reasons that can make it difficult.

It’s drastically improving. You’re seeing integration increase every single day in multi-platform environments, and that will continue. Will it ever be plug-and-play, immediate and easy? I don’t believe it will be, but it absolutely it is improving.

One of the reasons it’s improving relates to that scale we talked about. You’re now talking about $10 billion to $20 billion organizations that have 60, 70, or 80 hospitals across large geographical regions. You’re getting a level of inherent interconnection and integration among data. Things that had been fragmented or in separate organizational structures are now common and are exploiting the technology they have to to break down some of those cultural and political and competitive barriers.

What are the biggest challenges of healthcare IT consulting and staffing firms?

It depends on your entry point. We’ve just gone through a period of time that was the Wild West for consulting firms. We had a lot of entrants into this marketplace. There’s been a lot of work in our environment over the Meaningful Use period and beyond as people considered major platform changes.

You’ve seen a lot of entrants leave this market or have diminished performance because they didn’t have a long-term vision. We call them pop-up consultancies, companies that were taking advantage of a very hot market. God bless them for that, because everyone deserves an opportunity to do that. But we’ve seen a tremendous rationalization. The firms that are left in our space are the ones that had durable business models, paid attention to quality, paid attention to their associates, and most importantly, paid attention to providing value to their clients.

Only a few high-quality consulting firms are left that have weathered that transition. Those will continue to be successful. Our hope is that we’re one of those moving forward.

I guess there’s nothing inherently unhealthy that the industry flexed to meet the short-term demand and now has to flex back. What trends are swinging the pendulum the other way?

We feel really good about the next couple of years. This has been a very difficult or weird environment to manage a consulting firm. We’ve had boom and then site stabilization in this market. We believe that we’re back to a rational market right now, and the next five years will be a rational growth market within our space. Not boom or bust. We’re actually excited about moving forward. We think it will be much easier to run a business in this climate moving forward.

In terms of what we’re investing in as a strategy moving forward, digital health is number one. The concept of planning and solutioning digital health strategies for our clients is a big growth engine for us. The concept of virtual healthcare, whether it’s telemedicine or beyond telemedicine, helping our clients deliver healthcare in a virtual way is another big driver for us.

This market may not all be about our traditional provider space. There are other entrants into this market, these carve-outs. Even employer-based healthcare right now. We are working with employers that have geocentric employee populations, as an example, that are looking to develop internal healthcare systems. How you provide technology within those worlds is another of channel market for us, working outside our traditional marketplace.

ERP, enterprise resource planning, is another hot spot right now that many organizations are now looking at. Those systems have been in place for 20 or 30 years and now they’re replacing them after they’ve done their EMR. That’s another hot area for us.

Lastly, the thing that I think is going to be most important that’s driving a lot of our business is that after clients put in an EMR or have done a lot of their heavy lifting around some of their major systems, about four years after they convert, they take a look around and say, wow, we have an opportunity to kind of fix some of these processes. We maybe haven’t spent a lot of time and attention. We haven’t viewed it in a programmatic way. We had spent so much money on the systems and we’ve let them languish a little bit. So at about the four-year mark, a lot of our clients are popping up and saying, I need a programmatic way to optimize my clinical and revenue cycle solutions. This concept of optimization is going to be really big and we’re investing pretty heavily in that.

Do you have any final thoughts?

We’re excited about the future for a couple of reasons. But the one thing that I’m most excited about is that our industry spends a lot of time putting in foundational systems, while the next generation is about getting maximum value out of these investments. When we move up that continuum, we’re getting closer and closer to moving the needle for the patients, consumers, and families that we all serve.

It used to be that EMRs were going to be the best thing in the world for patients. They are, but they’re used primarily by caregivers. This next generation of conductivity, this next digital world, will have a direct impact on patients and families in a measurable way. Not only better healthcare, but lower cost, with better digital connections and ease of access. All these things that we’ve been working our entire career on. That’s what I’m excited about.

HIStalk Interviews Gabriel Orthous, CIO, Central Georgia Health Network

Gabe Orthous is CIO of Central Georgia Health Network in Macon, GA.

Tell me about yourself and your job.

I’ve been in the business for 20 years. I started my career in revenue cycle, moved on to analytics and population health, and now we’re in the throes of value-based care and providing an understanding around the risk-based models that payers and CMS are presenting. Being accountable and at the forefront of provider engagement.

We support 1,100 providers in our network. Every single modality aligns with Navicent Health, which is our major hospital in this area of Macon. It’s a large footprint of the providers that we support from a PHO perspective.

My background is a technologist. I’ve been an expert apprentice of population health and value-based care. I also teach population health at a couple of colleges as an adjunct professor. I’ve been at this game for about five to six years, seeing the transformation from a quality-based PQRS kind of perspective into, how do we make these things actionable? How do we quantify the effectiveness of these programs to lower total cost of care? Because at the end of the day, that’s what we’re trying to do.

How do you see a clinically integrated network changing the relationship between independent physicians and hospitals?

I’ve worked as a consultant with several types of CINs, many different flavors of those. The relationship between a hospital and the community physicians varies throughout the United States. For us, we’ve always had a strong relationship with our hospital system, being more on a regional level.

It depends on the market. If you come from an educational hospital or a medical center that’s inside of the perimeter here in Atlanta, for example, it’s a little bit different on how they deal with their independent providers. There’s a lot more competition. We’ve been able to build that relationship. It is a bit of relationship building, understanding the priorities of those physicians and enabling them to do the things they need to do to make the hospital successful and vice versa.

Is the trend of hospitals acquiring practices changing the dynamic between independent doctors and hospitals?

I’ve seen in the past 10 years the ebbs and flows of that strategy of going after physician practices and becoming employed versus affiliated. Again, it depends on the health system. You have a “who moved my cheese” ideology of some of the physicians who are now employed, because now they have an 8-5 job or now they have a set of requirements or standards being imposed by their employer, which is in this case the hospital. For them, there’s not that risk of having to pay the light bill at the end of the month. It lowers the risk for those providers to go work for the hospital.

At the same time, the hospital now acquires that risk, and acquires the risk of making sure that the productivity — and in our old fee-for-service world, the RVUs – stay up. But now that dynamic is also changing, because now you have quality measures, specific programs that are requiring these physicians to do certain things in closing care gaps, HEDIS, etc. that now the hospital needs to be able to influence.

It is a hard proposition. These providers are already employed by the hospital, and having some providers do what they need to do to close the care gap, for example, when they may not see an immediate benefit in that performance. But as a whole system, you would.

The idea of affiliation is important to understand. Inside the walls of the hospital, you can enact certain change. You have one view of the world through your EMR, whether it’s Epic or Cerner or any type of hospital-based system. But when you get out into the community, you see more of a diversity of EMRs. It’s harder to enact change when things work differently from a workflow perspective. Epic-everywhere or Cerner-everywhere types of environments are few and far between. At the point of care, it’s important to have an understanding of the topology of that network and become the network of truth as opposed to a single source of truth.

What technologies are important when first moving toward value-based care?

One of the most detrimental phrases in today’s healthcare space is saying, “I don’t know what I don’t know.” Unfortunately, many organizations that I’ve worked with are always saying that. There are different views of the world of how you look at your data, how you look at analytics. One is the clinical focus, the EMR perspective of workflow and patient-centered focused around clinical things that have to occur. Usually those are part of a system of trying to identify CPT codes or ICD codes in order to get paid through a billing RCM model. You have dichotomies of political and revenue cycle. That’s just one component.

On the other side of the house, you have the payer view of the world, which is adjudicated claims that come with a three- to six-month lag of information, telling the providers, “You forgot to do an A1c” or maybe asking the provider to provide a supplemental data set to close the care gap.

The way I look at value-based care today, and to prepare for a technology stack that’s able to be nimble, is to have partners. If you have the money to create your own, that’s great. But have partners that are going to be nimble enough, that are going to be helping you through that data journey and that have flexibility in advocating that data and making it be purposeful.

A lot of times we get into these projects or these technology implementations that are more of a Connectathon. Just send me all the data. Being purposeful, starting with the low-hanging fruit, showing value initially, success factors, identifying the right KPIs, and then building upon that.

So I would say, one, nimble. Two, a technology stack that can aggregate data from disparate sources, including social determinants, care management, and all the other data sources that are out there. Of course claims and of course clinical. Then number three is letting you look at the view of the world through those different lenses. Just clinical, just clinical plus RCM, clinical plus RCM plus post-adjudicated, social determinants, That’s when you start identifying the right populations and how to target things that are going to be part of your performance contracts.

Will being exposed to those technologies encourage practices that are less technically savvy to consider the possibilities of using other technologies to enhance their practices?

Absolutely. You’re bringing up a great point, which is point-of-care analytics and using technology and data to enhance workflows, patient experience, and the things that you just mentioned. But there’s also another component, which is the network view of the world. What are the things that are going to get these physicians the most money for their risk contract? What are the things that they need to do at the network level to have a critical path for patients to follow so that they have better quality and lower cost of care?

Those are two separate things. One is more episodic, while the other is more longitudinal. The technologies and the data required are a little bit different, although they come from the same sources.

At the point of care at the physician level, having additional data sets that are external to “patient presents” is important. I’m going through an HIE implementation right now with a local HIE here in Georgia. I truly understand the physicians wanting to see what happens outside their doors. When the patient presents to the ED, they want to see those discharge notes. That’s an important factor. The problem with interoperability and intraoperability is that those files become convoluted quickly. A CCD as it stands today is a bulky file. It’s hard to read and it’s hard to realize what’s important and what’s not important in there. So we lose a little bit of the usability factor in the technology utilization that we have today.

There are many new technologies that are coming about that are helping the providers focus on what’s important for the patient that presents in front of them from that external actor. But unfortunately, we’re not there yet with all of these EMRs. I’m not talking about one EMR or another. All of them have a lot of work to do around interoperability and parsing the right data set for the right patient at the right time.

What frustrates most people about interoperability isn’t practices not sharing information with each other, it’s that hospitals and practices don’t share information. How do your members see that situation?

It’s a challenge of not knowing what happens outside your doors, whether it’s the walls of a hospital or the doors of the physician’s office. More information is the best around medication adherence, for example. It would be awesome to understand what types of medications are being prescribed outside of that one encounter that you have with your patient.

It’s easier on the commercial side of the house with payers because it’s different types of populations. But when you get into Medicare, ACO, or frailty, for example … frail patients who come in may be prescribed seven medications in seven points of care. It is a struggle and a challenge for providers to understand the full totality and the picture of these patients.

From a workflow perspective, having only 15 minutes to spend with a patient diminishes the amount of value add. A lot of these providers don’t have access to the data. Not just the data, but having enough time to be able to have a conversation with the patient and have that relationship being built.

We still have a lot of problems getting external data into the point of care where it can pinpoint the providers to do the right thing with the data that they’re seeing in front of them that is actionable. It’s kind of a buzzword these days that everything has to be actionable, but it is the truth. These EMRs are becoming more and more convoluted, built on top of version, on top of version, on top of version, and not necessarily making it easier for the provider as opposed to death by a thousand clicks.

Are practices maximizing the value of that 15-minute visit by collecting more information from the patient beforehand and then following up with them electronically afterward?

There’s definitely an art and a science in that gathering of data pre-visit and post-visit. It really depends on the engagement level of each individual patient. We can have predictive models as to which patients are more likely to fill out a survey pre and post. But in general, I’ve seen minimal impact and engagement from that factor.

I took my daughter to a doctor’s appointment the other and they gave me an iPad to fill out forms, which I loved as a technologist. A generation X-er given an IPad to fill out the information. I even paid my co-pay on the IPad. It was beautiful. They asked me a thousand questions and it was great. It was death by a thousand surveys type of thing as opposed to clicks. Then I’d go in and the HIPAA paperwork was on paper and I had to sign that.

We still have a lot to do from an engagement perspective. I’m sure that there’s a lot of new apps out there that are trying to streamline that process. It’s getting better. Now if you send me an email three days later asking me for an opinion or a survey on my engagement with the provider, I’m not going to fill it out personally. But that’s changing.

Do you have any final thoughts?

No matter what a vendor or a technologist says, value-based care is a hard journey. It will take us numerous years to figure this out. We have an entrenched system of fee-for-service and we’re starting to see models that can help us to ease the transition towards value-based care. For now, we have the two-payment problem of “having food in two canoes.” I’m still in one canoe, and maybe one of my fingers is in the other canoe. Different markets are doing it differently, but value-based payments are here to stay and we’re not questioning that any more.

My suggestion is to think about it more holistically, more of a long-term plan. Have a one-, three-, five-year plan around engagement with your providers, engagement with your patients, technology enablement, ROI on technology implementations, analytics, and data for actionable insights. All these things have to be addressed. Distribution models, so when the payer gives you a downside risk capitation, how do you distribute that money? How do you make it flow to your providers?

There are a lot of things to think about from a strategy perspective. Be patient. It’s not going to change just because you buy a technology. People and process must be outlined before technology comes into a CIN or a network like ours. But having that strategy beforehand is important.

HIStalk Interviews Erine Gray, CEO, Aunt Bertha

Erine Gray, MPA is founder and CEO of Aunt Bertha of Austin, TX.

Tell me about yourself and the company.

Aunt Bertha focuses on the easiest way to connect people to health and human services programs through a simple interface. I experienced the need for this personally. My mom is permanently disabled. I have been her guardian for the last 17 years. Throughout this journey, I would find out about social programs after the fact. It was confusing to navigate.

I started the company nine years ago to offer an easier way to find programs and to connect to them directly and electronically. Some people call them referrals. We have 73 employees.

The concept of social determinants of health is suddenly popular, but for hospitals, it often just means having a place to record the patient’s self-reported information. Are they getting better at using that information to better transition their inpatients or ED patients to social organizations?

You’re right, there is a lot of talk about social determinants. It used to be called poverty and poverty alleviation. These are difficult problems to solve. The hospital system can do some things in many cases, but in a lot of them, they don’t have much control.

We have 175 customers, of which a good chunk are hospital systems. Many of them are just starting to record the assessments so they can at least uncover problems related to social care. Finding out if they need food or housing is a great place to start. They either turn on assessments in their EHR or they use our assessments.

That’s a great start, but some hospital systems that we’ve worked with have gone really deep. They have staffed social workers and teams who go the next mile and follow up with patients. In some cases, they actually buy wheelchair ramps, groceries, and other things if they find there’s a need.

I would say that the movement is still pretty early. It has been really neat to see how these hospital systems are experimenting.

Is it hard for hospitals to make a quick, clean handoff to community-based organizations that aren’t necessarily equipped to respond quickly?

Absolutely. You still have the issue of non-profit financing. A community-based organization, or CBO, could be a government program or a social service program. Many of them are dealing with long waiting lists and a lack of funding, Some can’t serve their existing population. It is a challenge.

The question then becomes, what is the health system willing to do to engage them further, and, in some cases, to allow for reimbursement for some of these services? We are starting to see the sector think about it. CMS is starting to think about allowing for reimbursement for non-medical services beginning in 2020 for certain situations, if that service is deemed by a doctor to be medically necessary.

The short answer is that it depends. Organizations that sit down with the community-based organizations, get to know them, and build a partnership with them have seen higher levels of success under that model versus just hoping that an underfunded social care network can handle even more demand for services.

These are hard problems. Healthcare should assume longer-term commitments to these financing issues. I don’t think software is going to fix it, to be honest. Even though we’re a software company, I think the broader conversation is, how are the health systems and the local community-based organizations working together?

It’s interesting that 50 years ago, hospitals weren’t very much different from other community non-profits. Somehow their paths diverged and hospitals became monolithic and highly profitable, while most of the rest struggled for funding and hospitals quit talking to them in focusing on delivering episodic services.

You’re reminding me of the book “The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry” by Paul Starr. It’s about how in the early days, people helped each other and how specialization within healthcare then happened. Your analogy is spot on. People did use to look after their neighbors a little bit more and there was tighter coordination. We’ve gotten away from that.

I entered the name of a remote, tiny town on your web page and it returned a list of 800 programs. It was nicely divided by the type of service and offered many simple but powerful ways to filter the list, mark favorites, make notes, and contact the organization. Your website says you have a large team manually maintaining that database versus other vendors who either unethically scrape your data or use a software bot to harvest information from the web. Why is it important to have humans doing the work?

It is incredibly important to us. If you put yourself in the shoes of a social worker or a doctor, they are sitting down with a patient and hearing about things that are happening in their lives. Maybe they need counseling, drug addiction help, or whatever the case may be. You learn very early on that the credibility of our users is on the line. The social worker is sitting down with a patient who is being vulnerable about their situation, which is hard enough. Referring to a program that doesn’t exist or that hasn’t been updated hurts the credibility of the social workers who are out there doing important work. We don’t always get it right, but we try really hard.

We determined early on that we wanted to build an operation of people for two reasons. One, because we think the product and the data will be better. That doesn’t mean we can’t automate some things along the way, and we’ve done some things to make those employees more efficient. But every listing is approved. We try hard to do this across the country, but we focus on states where we have customers and usage because we don’t have unlimited resources. That focus has allowed us to grow.

The team is 25 people and growing. That line item is one of the most expensive aspects of running the business. However, we’ve never spent any money on marketing or public relations. We’ve been able to get to know health systems, health plans, schools, foundations like AARP, and others just by providing a free search. We’ve started to get users that way. It has ended up being a good investment in the business in the long run.

Secondly, it’s a great way to find people in a growing organization. We’ve had many employees graduate from what we call the data fellows program, where they spend a year or two curating the data and verifying information. They become programmers, data analysts, and supervisors. We grow folks and get to know them. It’s a mutually trusted source. They end up doing great things with the rest of the organization.

It’s a win-win, the way we see it. There might be other approaches to maintaining a reliable database, but I don’t think they will win in the long run.

What is your revenue model and how does the community connection work?

We’re doing something different in healthcare. We try to make it simple. Smaller organizations can become a customer at a basic level, a professional level, or an enterprise level. We’ve learned that our customers don’t like seat licenses, per-user per-month models, or other models. We look at it differently than in classic health IT. We’re successful when we have thousands of customers out there paying us a modest amount. That de-risks us. If you are a health system, you can buy our enterprise version with a couple of add-ons at a set amount that is open, transparent, and explained on the website. That allows us to build trust with our prospects.

Once they become customers, we want lots of users. We don’t want to put anything in the way of that. The more users who are on the system, the more people who will get help and the more we’ll get our name out there. Our pricing follows models from outside health IT and it has worked well for us.

It’s also a lot more fun. We only have three salespeople and myself. When a sales team is getting 15 to 20 customers per quarter, they’re having fun. It’s an approach we feel really good about and our customers like that we keep it simple and transparent. This approach to pricing subsidizes the data operations team. We have been able to provide a free service at AuntBertha.com because we have enough customers to cover our costs.

Why is it important that you don’t require people to register before using your online service?

It’s understanding our users. We need to earn the trust of people who are in need, patients in the healthcare setting. We use the term “seeker,” which is basically anybody who is seeking services. Most people are not ready to identify themselves when they’re searching for help for their most intimate needs. Think of a breadwinner who loses their job. Maybe they’re not ready to identify themselves.

It’s an important principle that we allow people to look for things. We see what people are searching for. They are searching for sensitive situations, such as childhood trauma. They have the courage to at least search for help. We want to leave it as an opt-in situation because we build trust. Social workers who work in hospitals or community-based organizations also don’t like creating accounts, so we get their loyalty as users as well.

Once you start making referrals, you can identify yourself and make an account. But we are perfectly fine with users of AuntBertha.com and social workers who are using our platform to pick up the phone and call a non-profit directly instead. It’s perfectly their right to do so and we would not get in the way of that. But from a business perspective, that wins out in the long run and we get customers who want to opt in later.

How do you balance the company’s social mission as a public benefit corporation and your own advocacy work with running a business?

I don’t think they are conflicting. The trade-off in allowing for free users and that social mission side comes across during a deal cycle when we’re talking to hospital systems. Laying out what we’re about and what we’re trying to accomplish is a differentiator in that process. People can quickly tell the difference between an alternate approach that is on price maximization.

We are pretty close to break-even. Our growth and the number of potential prospects allow us to charge less, get lots of users, and still make a difference. We would not be getting into the doors that we’re getting into without the goodwill that we’ve built over the years by providing a free service.

Do you have any final thoughts?

I’m excited about the way healthcare finance is going. I’m certainly not an expert. I was a programmer by training. I worked in public policy with some state health programs. But what I see happening is that health plans and hospitals are starting to become interested in getting the basic needs of people met in non-healthcare or social care ways. They feel like it’s a win-win in the long run, for their government contracts if you’re a health plan, or under alternative payment models if you are a health system.

It’s an exciting time to watch this transformation happen. You’re starting to see teams being formed with the goal of, how can I interact with somebody in need at their moment of need? Could we as a health system or health plan solve that need by building a wheelchair ramp or getting them some groceries? It’s an amazing win-win. I don’t know what’s going to happen with government policy, but watching that is exciting.

HIStalk Interviews Ashish Shah, CEO, Prepared Health

Ashish Shah is co-founder and CEO of Prepared Health of Chicago, IL.

Tell me about yourself and the company.

I was previously the chief technology officer for Medicity, where I worked for about eight years leading up to the acquisition by Aetna. I stayed for three and a half years post-acquisition. Prepared Health is a Chicago-based company that is a little over four years old. Our platform connects hospitals and health plans to post-discharge providers such as post-acute care facilities, home care, and social determinants of health partners.

Your new customer Jefferson Health said in the announcement that they want to offer “healthcare with no address.” How are hospitals motivated financially to coordinate post-discharge care?

What’s been happening in healthcare over the last 20 years is a physical re-engineering. For a long time, care was organized around the institution, the community, the beacon, the hospital. Everyone could point to it. But there’s been an overwhelming amount of merger and acquisition activity as pressure increases over cost and improving the access in the community. Sometimes that’s care in the home, sometimes it’s rehab facilities or ambulatory sites. We’re starting to see significant re-engineering of physical assets and communities.

Jefferson is thinking about care not only in those care settings, but also virtually and on demand. You never know when you’ll have a moment that requires a healthcare encounter, so make it easier. President and CEO Dr. Stephen Klasko is a pretty special guy. He reminds me a little bit of Mark Bertolini at Aetna when he talked about quality equaling convenience. Trying to make life easier in healthcare, which is a mess, unfortunately. That’s why I started this company.

Who pays for your system? Do hospitals convince their local post-acute care providers to use it to manage their shared patients?

Like all early companies, we’re not immune to having to figure it out. But in our model today, everyone pays a modest subscription for the platform. We don’t have a limitation on the number of users, the number of patients who are managed, or the number of coordination moments that are managed through our network. That was by design. Part of the challenge is simplifying the entire go-to-market model.

Hospitals pay, but it is our ultimate responsibility to bring post-acute care sites — home health, other home-based providers, and community-based providers – online. That’s part of the value. It’s a difficult job, not only for hospitals, but for health plans, too.

Were hospitals already in regular contact with those post-acute care providers, or is it a new new relationship for the two groups to be at least talking, if not actually working together?

It’s starting to change. A lot of those relationships have been at the social work level. If you had a transitional care nurse or a licensed social worker who was managing that transition out of the hospital, they were the ones who knew the facilities and the home-based providers. It was a personal relationship. That’s how decisions were made on who goes where and for how long.

Cost and quality are bigger topics. You’re starting to see health systems start to invest in new roles, directors or VPs of preferred provider networks or post-acute care in addition to population health roles. There’s more of an effort to try to understand your partners outside of the hospital. The reality is that you can’t acquire enough providers. There will always be a capacity issue. These groups are trying to get a handle on who the very best partners are to invite into their preferred network.

The product screenshots on your site look a lot like Facebook. How important is the user interface when users work for post-acute care organizations that may not use much technology and who may perform all their work on a mobile device?

This is the principal design challenge. It’s extremely important.

If you don’t mind, I’m going to back up for a minute to talk about why I started the company. My father suddenly passed away six months after Medicity was acquired by Aetna. He was way too young. It was unfortunate. We felt unprepared. I was an executive inside of a healthcare business, but over the ensuing months after his passing, we spent time with people who were around him from a caring perspective. He was visited by home health aides. He spent time in senior centers. The toughest thing to understand was that many of these people knew what was happening with him, but there was no mechanism to share that information.

That was the most humbling moment for me. At Medicity, we had connected thousands of hospitals to many ambulatory care sites, yet nothing we we were working on was going to change our family situation with my dad. As I dug into the problem, there are 100,000-plus sites of post-acute home and community-based care. That’s being conservative. The challenge is a design challenge. How do you quickly organize a large ecosystem that the majority of the market says has no money? Why would you focus on that? Yet we know it is super critical.

When I left Aetna and Medicity, we looked at models like Facebook and LinkedIn. Although we had made nice progress, Facebook and LinkedIn had organized billions of users. Although our business model is not the same as theirs, there’s something to be learned from their design approach.

Sometimes technology just makes a process more efficient or transparent, but your platform does something that can’t be accomplished otherwise. You can’t get everyone from all these provider organizations and family members together at the same time in a conference room or conference call.

We are in a crisis right now as a country. Ten thousand people are turning 65 years old every day. People talk about the silver tsunami. It’s going to tax the healthcare ecosystem in a significant way, but 47 million people in the US are unpaid family caregivers. These are people who care and who are willing to do whatever it takes to take care of their loved one, but they have no coaching, no training, no access, no connectivity.

As much as I love many of the great healthcare IT companies that are out there, no one is really focused on this part of the space. What health systems and health plans are starting to talk to us about is that personal caregivers, family caregivers, somebody in the community, or post-acute care providers make up an important group of teammates that they need to get connected and coached.

What kind of interaction do family members typically have with the platform and the provider care team?

Our first version was full transparency, just the way I wanted it when I started the company. It’s not uncommon to see home health staff and all the different workers connected to the family members around an individual. Or maybe a skilled nursing facility is also involved. Everyone is in together.

The types of things that people are doing are escalations and managing interventions. If somebody has a fall in the home or if there’s a sudden change in mood or weight gains, those are prompted by the professional care team to the family members and communication around those moments is being managed. These are difficult moments for families and there’s a lot of emotion in these conversations. What we’re most proud of is that through our implementation, we’ve seen these two groups turn into one team versus two teams that sometimes let emotions get the best of them.

As we think about scaling that experience, our provider organizations have coached us to think about how to keep the convenience and access in place, but to think about this as two modes of communication — a back office communication channel where things are communicated in shorthand and then a front office communication channel where you have buttoned up or polished communication with the patient and family. The concern is always that somebody will say something that makes the organization look bad. We’re working through that with some of our earlier customers.

It would seem beneficial to allow caregivers who work for different organizations and who may rotate assignments to have a closed channel that allows them to take a conversation offline.

We’ve paired group-based communication with individual communication. We’re trying to attack any mode of communication. That could be an assessment, an electronic check-in on how you’re progressing, a referral, or a transition. We incorporate group and secure texting and chat into the product. Interestingly, we see high utilization of all of these across the board.

The magic is communicating with somebody outside your organization. That’s the biggest challenge. I spent 10 years working on data interoperability in healthcare and God bless everyone who is trying to push all that stuff forward, but I think we have skipped over the fact that a number of these types of things will never happen through an EMR. People don’t talk through EMRs. They don’t manage interventions in real time through EMRs.

What kinds of things does your virtual care coordinator recommend?

DINA is our digital nursing assistant. She was an accidental invention. It started with how we could create this rapidly growing ecosystem or community for communication. In our first implementation, we met Amie Martinelli from Bayada Home Health Care. I’ll never forget her. She did an amazing job of coordinating care for complex CHF patients. When we looked back at the implementation, we thought, how will we ever scale Amie? Is this what everyone in healthcare is doing? As we studied more, it is what everyone is doing.

Every great outcome is an exception. Someone has to put forth a heroic effort to make sure all the right things happen. That’s hard in a market where there’s 40-50% turnover. We thought that a combination of advanced analytics, AI, and all the other buzzwords could be an answer. Today, DINA is present in our network and she is aware of all the communication. When people integrate their data with our solution, we get our hands on rich functional, behavioral, and other types of assessments. She can recommend people who perhaps should have a particular type of service, who could be seen at a more optimal care site, or whose situation should be escalated.

One that stands out is hospice. Sometimes people are on home health for a long time. They are re-certified over and over and over again. A lot of that is because of the personality of a nurse. They never want to quit on a patient. We’ve taught DINA to identify that moment where perhaps it’s time to have a more difficult conversation around palliative care options or hospice. One of the things that you’ll never find in a hospice eligibility guideline is the inability to use the telephone, but our predictive models found that to be a huge predictive factor.

DINA is aware of a lot of the communication. She can recommend people for conversations around hospice or perhaps a readmission back into skilled nursing versus a hospital. She’ll notify people when they are crossing certain care guidelines. If somebody should have been in a skilled nursing facility for 10 days but they are on their 15th day, she will identify that and communicate it upstream. She can do a lot of things, but much of it involves intervention management.

The Jefferson Health contract gave the company a lot of visibility given its relatively modest amount of funding. Where do you see the business going?

We have been humble and quiet by design. We bootstrapped the company for two years because David Coyle and I were focused on understanding the market, solving a problem, and generating some revenue along the way. We raised a modest amount of money, $4 million, to build a team and enter a new region. We’re active in three states — Illinois, Pennsylvania, and New Jersey. We’re proud of the work in that greater Philadelphia market, which is a top eight metro market. We working not only with Jefferson, but also Holy Redeemer. Almost every major home health provider in that region is on our network and soon we’ll be adding many of the leading skilled nursing providers as well.

As we scale the business, we’re looking to take this national. We just added a new senior vice president of sales and marketing, which is a brand new role for us. But we feel like we’ve been doing this the right way. We didn’t oversell. We didn’t over-promise. We did the hard work of trying to understand the space and create a great product experience. We’re maniacal inside the company around Net Promoter Scores and engagement of the product. We stand on a solid foundation. That’s what we care about first and foremost. Do we create value, and do we create it at a faster rate than anything else that’s out there?

With a few wins under our belt, it’s time to pick up the pace on building the business. We have identified hot spots across the country where there’s a greater need, where Medicare Advantage and managed Medicaid in the aging population is growing faster than other places. We will zoom in on those as a starting point. We’re in a good spot to start to scale. We see a lot of companies that try to scale too fast. We’re in the right place at the right time, but we have to do the work like everyone else.

Do you have any final thoughts?

There have been a lot of competing incentives and sites of care. Nobody is trying to do the wrong thing. But the next major wave is Dr. Klasko’s “healthcare with no address.” Internally, we call that a never-discharge mindset. How do we care for an individual when they’re healthy, they have an acute need, or they move into the post-acute ecosystem? With the amount of M&A that’s taking place and the amount of change that is required, we need more people to adopt this never-discharge mindset. The caring never stops for the family or the individual, so it shouldn’t stop for the institution.

HIStalk Interviews Stephen Brown, Director of Preventive Emergency Medicine, UI Health

Stephen Brown, MSW, LCSW is director of preventive emergency medicine at University of Illinois Hospital and Health Sciences System.

Tell me about yourself and your job.

I’m director of preventive emergency medicine at University of Illinois Hospital and Health Sciences System. I run the Better Health Through Housing program, which identifies the chronically homeless in our emergency department and transitions them into permanent supportive housing. We’ve been doing this since 2015.

My background is in technology. I worked for Motorola for 13 years in a variety of capacities, starting off as a junior systems engineer and then ending up being a district sales manager. I was also a product development manager and a senior account executive. I transitioned into healthcare in 2005, working in the emergency room at the University of Chicago as a social worker on the South Side of Chicago, surrounded by 10 of the 14 poorest neighborhoods in the state of Illinois. Then I transitioned to University of Illinois in 2011 to start a preventive emergency medicine program.

What motivated you to move from a technology and sales career to becoming a social worker?

I always loved the technology, but being in sales, you’re only as good as your last sale. I just got tired of living under quota. Plus, after doing some career development things, I discovered I was an introvert and that was why sales was so painful for me. [laughs]

It was a career transition, a mid-life transition. By 40, I decided I wanted to do something that was more altruistic. I originally was going to become a psychotherapist and start my own private practice, but I worked for Michelle Obama at one point in my career at the University of Chicago. We had some discussions and I decided that I wanted to do bigger work than just one-on-one counseling. This was an opportunity to do more population health work.

Does simply giving someone who is homeless a place to live help reduce the high healthcare costs they incur, or is the next step to identify and address any underlying behavioral or dependency issues?

This partnership has been with the Center for Housing and Health, a supportive housing agency here in the center of Chicago. They have relationships with 27 agencies scattered around the city.

What we’re learning is that it’s a tiered approach. Many people will just require what we call rapid re-housing. We don’t quite have the answer, but we’re in conversation about tiering the approach based on psychiatric and substance abuse characteristics. They are medical conditions for homeless individuals. We had somewhat of a lower level. It was scattered site housing. It was permanent supportive housing, but it came with a housing case manager, somebody who’s not trained in medicine or in psychiatry. Despite that, we still had good outcomes.

Are views changing on our expensive system of providing healthcare services vs. funding social programs and public health projects that might reduce the need for them?

Some studies have been done on that. We have great sick care in the United States. We wait for you to get sick, and generally you’re going to be sicker because you haven’t had preventive services. We don’t do prevention, nor do we address the social determinants of health.

There have been a number of studies around around the world where the relative spending on healthcare is much lower. I think we spend 2.5 times per capita for healthcare here in the United States compared to other industrialized countries. Healthcare costs are excessive. I think it’s approaching now 17% of our GNP.

But the other thing that is missed is that other industrialized countries spend more on social services and on prevention services. Having a safety net in place goes a long way toward preventing people from getting a lot sicker. That’s where a lot of the attention is in healthcare now, what we’re calling the social determinants of health. If you don’t have a stable place to live, it’s difficult to manage any of your health affairs, let alone anything else in life.

We’re really good at individual care here in the United States. We focus on the individual. What has been missing in healthcare is hospitals taking responsibility for the health of the communities in which they serve. After all, I think it’s 78% of the hospitals in the United States are non-profit and must demonstrate some type of community benefit to maintain that non-profit status. That shift in focus says that we have to care about the health of the individuals coming from the communities in which we are anchored, and yet that’s been a big disconnect in healthcare.

The technology exists to be able to create community-based report cards. Hospitals should be held accountable for the health of those communities in which they serve. There’s a way to do that through clinical measures, like aggregated hemoglobin A1C in a community, blood pressure, and number of ED visits for asthma exacerbations. Those are all things that are measurable and that health IT could take an active role in bringing forth. That creates accountability for hospitals — perhaps even a collection of hospitals if they serve the same geography — to take ownership of the health of the individuals within those communities.

The alignment is clearer if the health system is also the insurer, such as Kaiser Permanente. Health systems keep getting bigger and spanning state lines. How will those mega-systems work with the many communities in which they operate?

It remains to be seen. We are seeing some activity from Geisinger and from UnitedHealthcare. United Healthcare Is working with the American Hospital Association to develop 20 new ICD-10 codes for social determinants that would be actionable. We can document these things, but unless we take action on those social determinants, they’re really not going to go anywhere. I’m in conversation with a Denver health plan right now about replicating the model that we’ve created and a number of other health systems around the country.

The most interest is coming from those integrated health systems that are both the provider and the payer. It’s in their economic best interest to prevent people from getting very, very sick. We’re beginning to get interest from managed care organizations, too, many of which are represented by larger health insurance companies.

In any state, 5% of the patients in Medicaid account for about half the budget. Generally those budgets can consume about a third of the state budget. Because we’ve been so focused on individual care, we’ve lost the forest through the trees on those. There needs to be some attention on more of a population health model, not only at the state and federal level, but also within some of those large health systems, too. There’s tremendous opportunity to manage the health of these individuals by looking beyond the walls of the hospital and saying, what is it in a community that is driving the exacerbation of disease and poor outcomes?

How you see the pacing of the buzz about social determinants of health being matched by the creation of programs that will make them useful for actually changing something?

What happens with social determinants of health is that we try to do it the old, inefficient way. We hire a bunch of people. We screen in emergency departments. We’ve had some experience doing that. We’ve only been able to hit maybe 2% of the entire ED population because we’ve done it in the manual way. Again, here’s an opportunity for tech to get involved. When you bring big data to bear on this issue, you can find lots of things that you can elevate for risk and make it actionable.

Adverse Childhood Events, or ACE, is being promoted by the CDC. The chronically homeless fit the same profile over and over again, as 60% of the chronically homeless or the homeless in general have what we call high ACE scores. It’s a 10-question questionnaire that predicts poor outcomes, the development of psychiatric illness, and early death, among a variety of things. It’s kind of astounding.

We found that our chronically homeless individuals fit the same profile over and over. You’ll find this is true in criminal justice, too. The higher the ACE score, the higher the probability that person is going to end up on welfare, will have a mental illness, will end up in the criminal justice system, and will die early. One or both of the parents had mental illness or substance abuse and it played itself out on a profile where that person ended up becoming chronically homeless and developed serious mental illness.

You can find those things in a combination of electronic medical records, in public data, and in credit data. A number of emerging companies are looking at data mining to find those folks who have elevated risk. For example, with classical homelessness — somebody who has fallen off the grid because they’ve had some financial catastrophe or income volatility in their lives — you can find those people easily in credit data. You can predict the risk of homelessness eight to 12 months before it actually happens.

The way healthcare responds to that is inefficient, but there are opportunities to find people with a high ACE score and intervene with them early, because you’re going to see it play out in a lot of different things that are going to result in poor outcomes.

I’ll give you a vivid example. When I worked at the University of Chicago, there was a lot of crack cocaine on the South Side of Chicago. We would often get women who had cocaine intoxication. They were hyperkinetic or manic. Once we allowed them to detox on cocaine, I’d go in and interview that woman. The doctors were focusing on whether or not she was going to have a heart attack, so they were looking at elevated troponin and all these medical characteristics. They had a medical course of action. They were treating the symptoms of what is a greater problem.

When I dug into it, I found that the typical scenario was that the woman that had been repeatedly sexually abused when she was eight years old by her stepfather or uncle and had undiagnosed PTSD as a result. She had a very high ACE score and we hadn’t done anything. We got her treatment for her substance abuse, but she probably needed treatment for PTSD, too.

How can technology fit into a program like yours?

The big piece of it is bridging the gap from healthcare into the community. The FHIR standard is a promising technology, but as we found with the CMMI Accountable Health Communities, there is a substantial gap in tech between health IT and community IT. Many people are still dealing with spreadsheets. If the provision of a social service or community-based services is going to be effective, we need to be able to track whether or not that person actually got the service. Then, was there a treatment effect from that service?

What we’re doing here on the West Side of Chicago with the West Side United effort — a collection of five hospitals — includes a lot of economic development. Things like wealth management classes. We’re doing local sourcing for our supply chain. We’re trying to partner with colleges to create a talent pipeline and steer kids in the community into careers in tech and healthcare.

But beyond that, we need somehow to bridge the gap. Some of the things we’ve been talking about is giving out case management solutions, so we have just one platform for the community that can provide data on the receiving end. Those are going to be some of the biggest challenges we’re going to be facing if we are really going to tackle these social determinants of health.

The other thing is that I’m a big believer in microservices and having the ability to have an app store kind of arrangement for human services. Something that is plug-and-play and easy for JavaScript programmers to integrate and exchange data with healthcare organizations. But we’re going to need some enabling technology on that. We have a grant with the JB Pritzker Foundation to do cross-sector data exchange. In order to drive clinical integration of systems, we’re going to need to be able to have some kind of common appliance that can manage the traffic and flow of messaging and interoperability between human services and healthcare. This is a particular issue here in Chicago because we don’t have a healthcare information exchange.

The other piece of is from an evidence-based public policy, to be able to track individuals and their service utilization. In an ideal world — especially with these homeless individuals that we’ve found to be very, very expensive — we’re only looking at the most obvious cases. But as a population, how could we look at their healthcare costs? We know they have elevated healthcare costs, but do we know for the entire homeless population what that looks like? We’re only looking at mostly the chronically homeless, those who have been continually homeless over for a year. We need to have more resources available to do interoperability for both clinical integration purposes and to bring together large public health data sets so we drive evidence-based public policy.

A fair amount of national empathy seems to have been replaced with resentment toward social programs and those they help. Is there a message of hope that these programs work and will be accepted?

You see these bright spots happening around the country. Bexar County, Texas, which includes San Antonio, has a psychiatric stabilization center where they divert people in psychiatric crisis to a center where they are treated. They don’t have to go to the ED or jail. There’s a lot of good work happening. It just doesn’t get publicized because it’s a little bit wonky.

My job is more public policy and aligning systems so that they talk to each other. I think that we’re going to see some tremendous benefits from those things, because no matter what your political affiliations might be, we’re discovering that at least with some of these populations, the solution is cheaper than the problem. We would all feel better about ourselves if we look at how we can care for these people in ways that will extend their lives and keep them from getting sick. It’s also the right thing to do.

Here in Chicago, we’re having extraordinary conversations with the jail, with Cook County Health, the other public hospital here, and with Illinois Department of Corrections. We’re creating a flexible housing pool that will result in more supportive housing, with about 750 new units coming online. We haven’t borne the fruit of it, but I’m optimistic that we’re going to see some major sea change in how we treat the homeless and other marginalized populations. Especially non-violent offenders. Can we offer them alternatives to prison or jail? I’m seeing a lot of work in the opioid crisis right now. The sheriff’s department is creating a diversion unit. Hospitals are learning that if you want to treat the opioid crisis, you have to go out to them. They can’t come to you.

The glass is half full, as far as I’m concerned. We’re doing a lot of great work that will bear fruit very shortly.

HIStalk Interviews Dan Dodson, President, Fortified Health Security

Dan Dodson is president of Fortified Health Security of Franklin, TN.

Tell me about yourself and the company.

I’ve been in healthcare for most of my career. I have always been inspired to give back to healthcare and patients. I have an MBA in health organization management and have always been intrigued at the concept of using my business degree to help provide better patient experiences. I’m blessed to do that at Fortified Health Security.

We are a cybersecurity company, a managed security service provider. We provide a wide range of managed services to healthcare organizations to help them combat threats and comply with regulatory requirements.

How does a health system decide where to focus their cybersecurity efforts and funding?

I have that conversation with organizations every day. The majority of healthcare organizations understand that it starts with a risk assessment. Pick a framework and do an assessment. From there, figure out where you have deficiencies or opportunities for enhancements. Every health system is different on what their next step will be, but the core of every good cybersecurity program requires performing an assessment of where you are, then driving your strategy from that.

Then, think about the perceived value of your cybersecurity spending and the actual value that you are receiving. A lot of organizations look to buy the next shiny security tool. The board and C-suite perceive that the purchase of that technology will better protect them from adversaries and from hackers. That is true to some degree, but when we implement those technologies within a healthcare environment and its many nuances, we lose sight of what we actually need to do to operationalize that technology.

I encourage organizations to think about not only how they are deploying capital for buying new technologies or implementing new services, but how they are making sure that they are working in concert with prior investments whether they are supporting them operationally to extract the value that they perceive those tools provide. Tools can be quite sophisticated, but they require people and process to extract their full value. We see a lot of under-implemented, underutilized technology in healthcare organizations that we work with.

Sensationalistic headlines talk about theoretical risks that have never actually happened in the real world, such as medical device hacking and inserting malware in medical images, which doesn’t seem to offer much incentive for a hacker. Are hospitals chasing those hypothetical problems instead of the duller but more dangerous ones that don’t make headlines, such as the usual email-launched attacks?

Certainly some companies and folks are chasing those headlines with their solutions. No single bullet will protect you and secure you 100%. You have to take a layered approach that is appropriate for your organization.

We do a lot around medical device security. The threat to medical devices is real, but we are seeing it manifested by adversaries and hackers using them as a jumping-off point to get to the valuable data, not necessarily to disrupt the clinical performance of that device. They use the medical device to get to EPHI.

What new cybersecurity threats have you seen recently that are most worrisome?

We are seeing a lot of just the fundamental attacks, such as insiders and users and clicking on bad links in email. Those are still some of the highest threats that face organizations. Attacks such as phishing and vishing are increasing and becoming more sophisticated.

We encourage people to think about the fundamentals of a security program. The unsexy things — patching, making sure that they are doing vulnerability scanning, making sure that they are identifying where they have EPHI, monitoring the networks, and looking at logs. The traditional core fundamentals. Often when we peel back the layers of what happened in a big breach, a user inadvertently or purposefully did something, or there was a lack of internal blocking and tackling for security. We encourage folks to think about whether they are executing a good, solid fundamental program before investing in the latest and greatest gear and tech.

Organizations that are forced to admit that they have been breached always claim it was a sophisticated attack and sometimes imply that a state-sponsored hacker was involved, perhaps to make themselves seem to the public to have been more security-aware than they really were. That can lead the organization’s cybersecurity insurers to refuse to pay their claims because they can say that implicating state hackers suggests an act of war that their policy doesn’t cover. What is the level of threat from state-sponsored hackers in healthcare?

Healthcare is vulnerable. ARRA and HITECH spurred rapid digitization that wasn’t always implemented on modern, secure networks and infrastructure. The increased amount of valuable electronic health information is stored on the path of least resistance. State-sponsored attacks and hackers look for the path of least resistance, so we are vulnerable at the onset.

You brought up cyberinsurance, which is important to understand. Procurement of cyberinsurance in a healthcare organization may or may not involve IT or security. It might be procured by the legal or compliance department. A cyberinsurance policy’s actual insurance binder contains the requirements for that policy to be in force. It is important that organizations know what’s in that binder so if they have an incident, they actually get paid.

We are seeing that during the claim review process, cyberinsurers are doing claw backs or denying claims because the organization wasn’t meeting the requirements contained in the insurance binder. That’s a critical area of focus. Don’t get a false sense of security just from having cyberinsurance. You have to make sure you are doing whatever the binder requires. It has gone unfavorably for healthcare organizations that failed to do that.

Why do we keep seeing major information exposure from unsecured servers that are open to the Internet?

Networks have sprawled over time with health system acquisitions and consolidation. We see that every day. This cobbled-together infrastructure and process allows it to happen. We are all shocked when it happens and of course we want to avoid it.

It goes back to the fundamentals and looking at root cause. We need to have asset inventories, know where our EPHI is stored, and understand how it is performing on our network and within our environment. Spending time on the blocking and tackling fundamentals reduces the chance of finding yourself in that situation.

Quite a few breaches were caused by a health system’s third-party vendor. Has anything changed with regard to the role of business associate agreements in a security plan?

It is important to understand third-party risk, the types of data you are sharing, and how you are sharing it. The lines of responsibility have become blurred within the context of those types of relationships.

It’s important to have business associate agreements in place. I always chuckle when I say that because we still find people not doing that. Then it’s important to have risk stratification of those third-party partners to make sure that you understand what they’re doing from a security perspective to better isolate the data that we create and that we’re responsible for safeguarding.

How common is it for a health system to have a chief information security officer position that is staffed by someone whose credentials would qualify them to work outside of healthcare?

There’s a human capital problem in cybersecurity for all industries. Depending on what rags you read, millions of cybersecurity jobs are open worldwide at all levels. As you narrow that down to healthcare specifically, we see that a lot of the larger organizations have a CISO on staff full time. When you get to the mid- market, they probably have a person who is dedicated to security, but who has other functions as well. The organization may engage in some type of virtual information security offering to offset that, to bring in expertise and guidance without necessarily keeping somebody full time.

The big challenge is that the role turns over every couple of years. Folks do not tend to stay long in this job. That can cause challenges for the healthcare organization because they’re changing strategy every couple of years when the leader changes.

Do you have any final thoughts?

We are in an interesting time with cybersecurity and the threat landscape. I’m encouraged by the progress that most organizations are making in this space. I encourage everybody to continue to focus on the fundamentals. To those who have partnered with Fortified and our employees, thank you for driving our mission to increase the security posture of healthcare.

HIStalk Interviews David Wenger, CEO, Bridge Connector

David Wenger is founder and CEO of Bridge Connector of Nashville, TN.

Tell me about yourself and the company.

I’m the founder and CEO of Bridge Connector. Bridge Connector is an integration platform as a service with a data-driven workflow automation solution. It is focused on solving the business workflow aspect of healthcare and creating interoperability between systems and ease of communication without the need for code. It is a truly scalable platform that provides an affordable solution to any sized healthcare organization so that they can streamline their business use case workflows.

It’s unusual for someone with no healthcare or IT background to be diving deep into the technical aspects of interoperability. How did that come about?

I grew up around the medical field. My dad’s a doctor, a businessman, and an entrepreneur. I watched him my entire life and learned from him about healthcare and why it’s broken. I’m an entrepreneur. I started a marketing and advertising agency about six years ago that focused on branding, marketing, web development, and cool tasks like that. It focused on helping smaller healthcare systems, drug rehabs, and behavioral health facilities with marketing to get customers in the door as well as keep customers or patients. I learned healthcare through that.

I saw a really big problem with one of my drug rehab clients. We were hired to integrate their Salesforce instance with their electronic medical record software. They were getting 150 phone calls a day and had a full team of people in their office typing the information manually from one system to the other. It was a 30- to 45-minute process per patient. I said, we can build this integration, and it took about six months.

After we built that first integration, I thought that there must be a faster way to do this, where any of these drug rehabs or smaller healthcare organizations could connect System A to System B without having a full team of people trying to build the integration on a custom basis or manually typing the information back and forth.

My father owns a surgical center under Envision Healthcare, which is a very large company. I spoke to people at the company and learned that this is a problem across all of their surgical centers and doctor’s offices. They have no way to get the data from the doctor’s office to the surgical center, or vice versa, without having to manually type the information back and forth.

I decided to do more research and build a proof of concept. I hired some smart developers and bootstrapped the whole thing out of my own pocket with some help from some friends and family. We built and deployed a fully-functioning, working prototype. We partnered with companies like Salesforce, for example, in taking this to the masses, focusing on smaller businesses at first and scaling it from there.

Systems can talk to each other in many ways — FHIR, APIs, app stores, and traditional vendor interfaces. What are the technical and business challenges in solving the interoperability problem?

There’s a lot of standards out there, and a lot of companies that are stuck with the systems that they have. The solutions that are coming out are around API management or coding to specific APIs to build integration, so that developers have a tool they can easily use. We’ve taken a different approach. We have focused on meeting our customer at the spec their core system uses, whether it’s FHIR, HL7, API REST, SOAP, or a on-premise server solution.

We’ve created a way to connect to any type of standard and not make our customer have to code to any of those specs. We do it for them. Our platform is capable of digesting any of the types of information into one to make it a truly functioning integration. A solution like ours can go to the masses and be deployed to any type of healthcare organization, regardless of what system they’re using. As long as there’s a way to connect to that back-end system of truth or the other systems of truth, we have a way to do it, regardless of what standard they’re using.

What developments have you seen in making sure the information being exchanged makes sense to both sides and that it is inserted into the workflow at a point that makes it actionable instead of just making it available for a manual lookup?

We are focused on solving the business problems of healthcare. The problem in healthcare isn’t just clinical data. It isn’t just sending data back and forth. The problem is automating the business problem of healthcare. What drives physicians, what drives hospital organizations, isn’t just the money and patient care, but it’s automating the workflow so their daily processes can be as smooth as possible.

The government is saying to focus on interoperability. They’re trying to put a focus around it and develop it, making sure EMR companies or other vendors have fully-functioning APIs or FHIR standards. They are focused on trying to solve this problem. Companies like Bridge Connector and some of the other players out there are focused on building a standard that any sized system can easily connect to.

How do you work with traditionally low-technology, small-scale providers such as long-term care facilities and small medical practices?

We’ve partnered with the EHR companies in the long-term, post-acute care space. Their customers are requesting this type of integration and the ability to have their data flow easily. We partner at scale with a Salesforce, Clinical Care, or Brightree, for example, and provide a solution to all of their customers. The unique part about our platform is that once we build the connector or build an integration with one vendor, we’re able to rapidly deploy it again and again and again without the need for code.

Time to value, especially from a marketing brain, is everything. The faster you can go live, the better. The longer it takes, the more money the organization is losing. These smaller-sized facilities that aren’t at the leading edge of technology are trying to find ways to streamline their data so that they can solve their business workflow problem and then maximize their revenues by automation.

How does your social determinants of health functionality work?

We are launching our social determinants of health application. We’ve built a fully-functioning application on top of Salesforce. Anybody who owns Salesforce, such as a payer or large provider, can download this application that we’ve built — when it becomes available in the next month or so — and provide social determinants of health within their Salesforce org. They’re not only automating their workflow with integration and utilizing Salesforce to have all their customer data in one customer-centered place, but now they will be able to remove the barriers of care to their patients through this application that they can automatically deploy within their existing Salesforce org.

Salesforce made some healthcare-related announcements a couple of years ago, but I’m not clear what they are actually doing or who is using their product. How do you partner with them?

They are obviously a very, very fast-growing company. They have a significant interest in the healthcare space. They’re are doing a great job of providing value to the customers from a business perspective and automating that customer-patient view.

We partner with Salesforce to help the customers that they’re signing or customers that need integration. We partner with them to help automate those integrations and make them faster and make them easier to deploy, providing affordable solutions so that they can focus on what they need to focus on, which is obviously taking care of the patient.

Salesforce enables them to market to their patients and to schedule their patients. The functionality of Salesforce in healthcare is extremely impressive. We’ve been happy to partner with them and are excited to see where that goes.

What’s it like working with Salesforce, which was built on the concepts of openness and partnerships, compared to an EHR vendor?

Some EHR vendors have been slow to recognize that their customers want to be able to have the data flow as it needs to and to get the reporting that they need easily. The goal isn’t to take the data out of the EHR or make the EHR any less important to the healthcare organization. The EHR is important for the success of the business from a healthcare side as well as the patient.

The reputation of that openness of data is growing. EHR vendors are grasping the need and responding to what their customers are asking for, with integration and being able to have the data flow wherever it needs to. Obviously in keeping it secure and removing the identifiers and stuff like that. Salesforce is extremely secure. Bridge Connector is extremely secure, as well as the EHR. The core focus is taking care of the patient data and making sure it’s as protected as possible.

The company has grown quickly in headcount, customer count, and funding, but some see the healthcare IT market leveling off to some degree. How do you see that growth continuing and what will drive it?

We launched a year ago and we’ve raised $20 million so far. We had five people about 14 months ago and now we have 75 full-time employees. There’s such a need and so much customer demand for integration. Interoperability as a buzzword is more than just sending clinical data back and forth or patients having access to their medical records. The problems exist with the business use case. The markets that we’ve targeted, such as hospitals, are at the leading edge of technology.

We’re focused on the commercial space of healthcare. We are solving that business problem for those commercial vendors that can’t necessarily afford to spend money on a custom integration or developers building out integrations. They need is a rapidly deployable, affordable solution that generates immediate ROI.

We’ve grown so fast because of that, how we’ve partnered, and who we’ve partnered with. The overall need in the marketplace for a solution like what we have is driving our growth. Our growth is pretty astonishing to me, as someone who’s been here since the beginning and saw the idea and where it has taken us.

I think we are just getting started, to be honest. I think the growth will continue. We’ll continue to double in size. We’ll continue to rapidly increase revenues and customer counts and provide a solution that’s easily deployable to the masses over and over and over again, and at scale. We’re looking at hundreds of systems being rapidly deployable without the need for code over the next six to nine months. In healthcare, that solves a huge problem.

While the market might be leveling off a little bit, we think it will hit another inflection point in the next six months, where we will just continue to scale rapidly.

Do you have any final thoughts?

Healthcare is a semi-broken industry. Doctors need to focus on taking care of patients. A guy like my dad, for example, goes home every day after seeing 35-40 patients and types notes or does follow-up work on each patient. It’s an extremely draining task because of the need for notes or documentation, which are important, but there’s no way to easily do that.

The faster that the healthcare market allows for full interoperability or full connections between systems without EHRs getting in the way, from a API being available or charging customers lots of money to be able to have these integrations. As the market keeps growing, there will be a continuing need to connect systems, make the data actionable, and let the business automate workflows, Otherwise, the healthcare industry is not going to get fixed.

The way to fix it is to first solve the business problem, allowing System A, B, C, and D talk to each other. They can do that in every other industry in the world. Why can’t we do that in healthcare?

As a company that has grown as fast as we have, we feel that over the next year, we can help provide that solution to the masses. Not just hospitals, not just large enterprises, but to a small doctor’s office so their system can talk to other doctors’ offices, or have it talk to their billing system without having to go to their EHR vendor and paying thousands of dollars on top of the actual integration costs. The goal is to be able to deploy this to the entire healthcare market, not just the enterprise.

HIStalk Interviews Luis Castillo, CEO, Ensocare

Luis Castillo is president and CEO of Ensocare of Omaha, NE.

Tell me about yourself and the company.

Ensocare is a care coordination platform that helps move patients to the right level of care along the care continuum. We’ve been doing this for about 10 or 11 years and I’ve been there five years.

I’ve been in healthcare IT for a long time. I don’t think I’ll ever go back to big company. I’m having the time of my life running this small company.

What are the benefits and challenges for hospitals in getting discharged patients placed and coordinating their care afterward?

The big EMR push, Meaningful Use, and even ICD-10 took people’s attention away from the post-acute care side. What happens once you leave the hospital? I lost my brother about two years ago and I remember trying to get him placed into hospice. I had to go to our network and ask my team. Who is available Des Moines area? What are their CMS scores? Because the hospital handed me what looked like the cardboard filler that comes in a shirt. It was laminated and had a bunch of numbers on it. Some were scratched out, some were written over.

They said, here you go, it’s up to you. Make some calls and figure out where to put him. There was no automation and no ability to tell me which facilities were better or which ones weren’t. That discharge and placement process is highly fragmented and not very process driven.

We put automation and technology behind this very manual place. Nurses typically stand in front of a fax machine for 5-6 hours a day getting this done, so we let them go back to working at top of license and get them back in front of the patient — case managers, social workers, and so forth. But we also impact length of stay, so if I can decrease it by a quarter-day for patient population, that’s big money over the year.

Hospitals sometimes leave placement decisions to the patient and family to make sure they aren’t accused of playing favorites or being held accountable for placements that don’t work out. Is their challenge in advising patients and families due to lack of knowledge or a reluctance to exert undue influence?

That’s a really tricky question. I still remember when health providers and payers couldn’t even be in the same room together. There was this hatred for each other. But now health plans own hospitals and hospitals create their own health plans. With some of the Medicare Advantage plans, people who are taking on risk can manage and direct patients to places if it’s their own population.

But you bring up a great point. The IMPACT Act says you have to give a patient choice. You have to disclose any financial relationship you have with that home care agency or that behavioral health provider that is affiliated with your IDN.

Our system lets you put all the choices in front of the patient and give them an unbiased score, such as the CMS scores for quality. They can flip through almost a Hotels.com interface on the tablet and look at the places that have a bed available. They can see if they are pet friendly, check which churches are nearby, see a picture of the area.

Hospitals aren’t supposed to direct people or to steer them. They have to manage that closely. Our application helps document that they gave the patient choices.

In the absence of something like a Tripadvisor that includes detailed reviews and scores from individuals, should I as a patient or family member trust the CMS star ratings?

We’ve been asked by our customers to do some kind of independent rating score for post-acute care facilities based on the data that we have, such as readmit ratios and quality scores. But I’ve been hesitant to do that. We offer the post-acute care network a free portal. We don’t charge them to belong to this, although some of our competitors do. We try to get them to be engaged, to answer inquiries within 30 minutes, and to keep their engagement level up.

We have something that is more on the predictive side on our roadmap. Predictive analytics that say, based on what we know of this patient and the performance of organizations in our network, here’s where we think this patient will do best. They need DME, infusion, dialysis, and these levels of care, and these places do really well with that. I don’t want to become a Class II device and make a clinical recommendation, but I will start scoring and show them a predictive model.

How important is it to have access to actual empathetic humans and not just technology and information when making what could be one of the most important decisions in someone’s life?

I remember when Gateway and Dell came into the PC market. Nobody thought they would ever pick a laptop or desktop off a pick list since technology was intimate in some ways. You wanted to see it and touch it. You would never buy it sight unseen. But the paradigm has shifted. We buy online, even for major purchases like cars, and just have it delivered.

You probably won’t pick a provider via technology, but you’ll get a list of 10-12 places that have a place for Aunt Betty. You take a look on the tablet at their quality scores and decide which three to visit because they meet the criteria. You’ll physically go and take a tour to see if it’s the right place.

The predictive modeling will make it more interesting in being able to show outcomes and recommendations. I’m not sure if I’m going to develop a Yelp-like thing, but people want to know what other people felt about their visit there and what it was like.

It’s also true that everybody is not in the same financial situation. We are looking at working with payers to provide an estimated out-of-pocket expense. That is powerful because you may not be able to afford the five-star rated place.

Given that not everyone is willing or able to pay for a Ritz Carlton, can someone with a Motel 6 budget at least look up how satisfied others like them with similar expectations were with a particular facility instead of just comparing absolute satisfaction numbers?

Not today. The closest thing involves discharges, although it’s hard to quantify with so many variables and I can’t say for sure if I’m impacting it. But we’ve seen a big change in HCAHPS scores. On discharge, people afterwards didn’t understand the discharge because it was in the wrong language, she spoke very quickly, they were pushing me out the door, the ambulance was late. They list all these things, but an HCAHPS-type measure does not exist for the post-acute care visit right now. But as you start managing populations, I think it’s coming.

What does a hospital need to do to get started with your program?

They start by listing their favorite facilities in the area, the ones they use frequently and discharge to most often. We build that into a quick list in the system. We reach out to all those post-acute care providers, train them on our portal, and get them to understand that there’s an engagement value here that says you have to answer referrals within 30 minutes. Seventy percent of Ensocare calls are outgoing as we are managing the network. That’s different from some of other solutions that just buy a CMS database, import it into their system, and call it done.

I build my database organically. Every time I do these outbound calls, I know which facilities aren’t responding. Our customer support people and customer experience people call them proactively to say, we notice that you aren’t responding to the referrals we’ve been sending you. Is there a problem? Many times it’s, oh, the lady that had the app on her phone left and we don’t know how to answer any more.

We deal with post-acute care facilities that are very technically advanced and are part of large national chains. But we also work with home care mom-and-pop organizations in rural parts of the country, so it can be challenging. But we actively engage and manage the network to make sure they are responding.

You wrote after HIMSS19 about how smart speakers like those powered by Alexa might be used in healthcare. What do you predict?

The interface is becoming more reliable. Nine times out of 10, Siri or Alexa gets it right. One of the biggest potential uses I see is managing the population after discharge. Once you get a risk score through LACE or some other technology, you know that this patient has two co-morbidities, is high risk, and has a lot of social determinants. The nurse wants to follow up, but they’re going to call you, ask you to enter information into a mobile device on an app. Many patients aren’t all that technology savvy. But if you send them home with a smart speaker, it could automatically populate population health platforms with vital signs. The nurse is now calling only the people who need intervention as opposed to calling everybody every day. That model is unsustainable.

I recently was at a hospital that had a warehouse full of 75 nurse navigators. All they do, all day long, is call people. I’m following up on your primary care visit. Did you pick up your prescriptions? Did you do these things? Tools like the smart speakers are going to begin to invade that space.

Do you have any final thoughts?

I worked for two large companies. Shared Medical Systems taught us how to be close to the customer. Siemens, true to its German engineering background, taught us all about process and engineering. A healthy combination of both of those things is appropriate.

But the one thing that can’t be supplanted, the one thing that you always have to keep at the top of your radar, is high-touch customer service. We have a person at the end of the phone each time. You don’t get routed and automated and have to press two and three to talk to a representative. We have a high-touch customer service that our customers appreciate.