HIStalk Interviews G. Cameron Deemer, President, DrFirst

G. Cameron “Cam” Deemer is president of DrFirst of Rockville, MD.

Tell me about yourself and the company.

I’ve been president of DrFirst for about 14 years. DrFirst is primarily a technology platform company working in the medication management space. To de-jargonize that, we provide core technologies such as electronic prescribing, controlled substance prescribing, and a lot of things around medication history and interoperability. Those are often included in EHR platforms, hospital systems, HIEs, and pharmacies. We have a pretty broad footprint across the industry.

What is the best source for an accurate medication list other than asking the patient or their family members directly?

I would say DrFirst, of course. [laughs] Seriously, the medication history lists have come a long way. There has been a core medication history list provided by Surescripts for many years. We take that list and add medications to it from sources that aren’t providing their med history to Surescripts.

Getting a complete list is one issue. The other is making sure that the list is in a format that a hospital can intake into their own system. We do considerably massaging of the feed to make sure it has the right data elements. We clear up any discrepancies, such as around drug descriptions versus the NDC numbers and things like that. Then we help hospitals be ready to intake information from outside.

The best source is really a hospital or a physician that is using a very strong industry feed. It’s continuing to get better all the time.

It has always seemed hard to get old medications off the list, which could be done either by asking the patient if they’re still taking it or checking their refill records. Is that still a problem?

One of the things that’s exciting right now is being able to involve the patient more in that discussion. Medications they are no longer taking are one thing, but probably the more relevant issue these days is that patients are deciding how to medicate themselves. For example, it’s difficult to get a good, complete list of nutritional supplements that a patient might be taking.

But the other issue is that if I prescribe you a drug and you have some kind of reaction to it, maybe you decide that you’ll only take half a pill instead of a whole pill. Or maybe you discontinue it for a few days, you feel better, then you take it again and you feel bad again, so you discontinue it. Knowing how you’re dosing yourself versus how the therapy was prescribed to you needs to be addressed. We’ve been working on that primarily through more mobile interaction with patients, helping them understand how the doctor views their medication records and giving them a chance to update those appropriately for the physician.

I’m interested in your Link app, in which the patient receives a message under their doctor’s name listing the medication that was ordered, where their prescription was sent, and how much money they will owe as their co-pay. It even allows them to schedule a pick-up time with the pharmacy. Does offering a patient-facing application give DrFirst a way to grow in a new way?

It does. You and I talked about two years ago when we were starting beta testing of Link. We went into full-blown production with it within the last several months and have sent it to millions and millions of patients.

The way it works is that we know you’ve been to your physician, so we will reach out to you and try to make sure that you don’t abandon your prescription. We try to deal with what’s on your mind at that time. How much is it going to cost? What am I taking this for again?

A survey we did recently found that nearly half of all consumers aren’t sure they can take the medicine the way they were directed to take it because they can’t remember. The physicians usually are in kind of a hurry and the patient’s not thinking because they’ve just been diagnosed with some issue. Imagine that you were just diagnosed with diabetes or with high blood pressure and you’re not sure what that means. You’re not sure how you’re going to tell your spouse about it. You’re worried about how it will affect you physically. You may not be listening that carefully while the doctor is running through how you’re supposed to take your medicine.

We try to fill those gaps by reminding the patient. These are the meds that were prescribed. Here’s the pharmacy that has your prescription. Here’s some information about that therapy to remind you of the things your doctor told you. If you’re worried about how much it’s going to cost, here is the co-pay amount. Here is a financial assistance program, or maybe a consumer discount card if you don’t have insurance, which a lot of people don’t these days, or maybe they’re in a high-deductible plan. We take that cognitive load off the patient of not being able to remember what to do, being afraid of what they might have to do, and worrying about it. We ease them into starting their therapy.

I’ve always felt less empowered with e-prescribing. Before, I had a piece of paper that I could carry around to shop prices, I could get the prescription filled whenever I wanted, and I could research the drug before going to the pharmacy. Now I’m barely out of the doctor’s office when Walgreens starts the robocalls telling me to come pick up my prescription. Does Link re-empower the patient?

That’s an excellent observation. I actually feel the same way when I get a text message from the pharmacy telling me to come pick up a prescription. I may not have even been thinking about that at all. It’s just all happening in the background somewhere.

Another element of that is the rise of patient portals. On the one hand, it’s positive that we’ve been getting federal pressure for patient portals to be available in every EHR system, every hospital system. But it’s another way of taking some control away from the patient. Their data gets scattered between many electronic systems. It’s hard for them to bring it all together in one place. It’s hard to even just remember how to get to your portal a lot of times.

By going after the patient with this mobile solution only when they need it, we are trying to empower the patient to have all of their information in one place so they don’t have to remember what to do in order to get their questions answered. That’s probably the key here. As things become more electronic, there’s no reason that the patient should have a miserable experience of trying to navigate those electronic pathways.

Is the prescriber notified if the patient uses Link and decides for whatever reason to not pick up their prescription?

Not today, but we will have that shortly. We are incorporating a secure messaging channel from the patient back to the physician.

This is a new concept. Historically, physicians haven’t communicated with patients through text messaging, secure text, for a number of reasons. But that recent survey I mentioned found that an enormous number of patients, like 90 percent, said they would rather receive a text message from their doctor than a phone call, being steered to a portal, or being contacted via any the other methods they would normally get. We’re trying to meet patients where they are and give them the tools to be able to communicate something back to their physician in a manner that’s efficient for both the patient and the doctor.

This is a brave new world of trying to address what we call the care triangle. Think of a triangle with the physician on the top, a pharmacy at one corner, a hospital at the other corner, and the patient in the middle. Everybody needs to interact with and talk to the patient. But also, everybody at the corners needs to communicate back and forth with each other. We’re using secure collaboration tools to let all of those entities talk to each other in a real grassroots way so that we don’t have enterprise boundaries any more, or divisions between the medical professionals and the patients they serve. Letting everyone have the tools to be able to talk back and forth.

We hope that will be an important next step in making sure that all of the people who are working on behalf of a patient can synchronize and coordinate their care and to allow the patient to understand what’s happening and to be a part of it.

It would be interesting to put the patient instead of the provider at the center, with each patient having their own Facebook-like page in which all those messages and the patient’s replies are collected in one place that the patient themselves controls. Is that possible?

That’s actually what it is today. From a provider’s point of view, when they’re in our secure collaboration tool, they’re seeing one thread for a patient. It’s like text messages, with topics bouncing all over in the thread. In the collaboration tool, it’s centered around this patient that the care team is working on. From the patient’s point of view, everything comes into one queue where they can see a consistent record of the communications they have had.

What is the impact of an app that targets the patient specifically?

Link is quite powerful. We’re seeing close to 25 percent improvement in prescription abandonment just through Link. But we know that some patients, and particularly those who care for patients, need a more persistent experience.

But we also know at the same time that patients don’t care as much about their health as we would like them to. They don’t consistently focus on it in a productive way, which is why we forget where our portals are. We’re not in them all the time checking on things and sending messages back and forth. It might be because people don’t want to be defined by their illness. It might be that it’s just too psychologically heavy to continually think about your illness. But we tend to be concerned in spurts when we’re ready to pay attention.

A key focus for DrFirst is reaching the patient only at those times that they really care. During the times when they have less concern, we are just being available if they need us. We aren’t trying to get their attention during those times. We think that most patient applications fail because they assume the patient will be interested enough to continually interact with the application. We’re trying to put ours together in a way that addresses actual patient needs when they are occurring without requiring a lot of other activity otherwise.

What’s being done with opioid prescribing?

With all the pressure for physicians to use EPCS, it’s now about efficiency. Physicians not only are required to order the prescriptions electronically, but they also have to check the PDMPs, the state controlled substance registries. That is such a burden.

I saw my family physician recently and his office gave me three pieces of paper when I walked in. The first one said, you need to acknowledge that we don’t write controlled substance prescriptions out of this office. They made me sign that. The second one said, if I do write you a controlled substance prescription, I’m only going to write a three-day supply, and then you have to come back and see me again and pay for another office visit. I signed that. Then the third one said, the state of Arizona requires me to check the PDMP and they won’t pay me to do that and neither will your insurance company, so you have to pay me $15 for every controlled substance prescription I write for you. I had to sign that.

That’s happening all over the country. Doctors are pulling back from prescribing opioids because they don’t want to check the PDMPs. It’s too onerous. We’re starting to create a crisis of pain as opposed to a crisis of overdose.

To alleviate that, we’ve been putting a lot of effort into making electronic connections to every available state PDMP and then bringing the information into the physician’s workflow. Instead of leaving your EHR, authenticating into another system, entering patient demographics, and then going back to your system and typing the information in — because typically you’re not allowed to download it, you have to retype it — we make it so that right in the process of writing the script the opioid history is just right there, with no effort required. This addresses what unintentionally has became the next issue of patients — their doctors being unwilling to care for their pain at all as a rebound to the epidemic in the form of “let’s just not write them.”

It has been gratifying to see how enthusiastic physicians have been about making it this intuitive. It ought to be this simple and we’re we’re making it work that way for them.

Do you have any final thoughts?

We’re entering a time when there is so much pressure on the EMR community to continue to build features into their EMRs. We’re starting to lose the connection to the patient. The next big opportunity is getting all this information that impacts patient care in front of the patient at a time when they are ready to accept it and in a format that they can put to practical use as part of their therapy.

Patients for too long have been treated like miniature doctors who are laser-focused on their care. People don’t really work like that. I’m excited about digging in at the grassroots level to provide solutions to the real problems patients have trying to initiate and maintain their therapies over time.

HIStalk Interviews Grahame Grieve, FHIR Architect and Interoperability Consultant

Grahame Grieve is a principal with Health Intersections of Melbourne, Australia and was the architect-developer of HL7’s Fast Healthcare Interoperability Resources (FHIR, pronounced “fire”) specification that allows EHRs to exchange information.

Was it weird to see FHIR as the only universal topic of HIMSS19?

Not so much weird. Obviously it was gratifying for us to see the community investment that so many people have made becoming justified. It’s definitely worth saying that we really value HIMSS’s active participation in driving the conference in that direction. There was an organicness to the fact that FHIR became the big issue given the way the industry overall is, but HIMSS definitely actively drove that and that was an important part of the picture. I thank Hal for pushing that.

I thought there was maturity at the HIMSS meeting this year. You and I talked about bad FHIR puns and expected to see them all over the place, but we didn’t actually see anything like that. We saw instead quite a lot of maturity around the discourse and the challenges of sharing data. I thought that was really good.

I always call you the father of FHIR without asking you if you accept that title. Is it fair or unfair to call you that?

I did initially draft it and propose it and I’ve curated the passionate community input over the years. If that makes someone the father, then I guess I am. The community is the real father. I get undue attention as if it was some magic that I achieved, where actually it’s just thousands of people passionately contributing to the common values that we hold.

I’ll repeat a question that I asked you last time we spoke. Are you worried that non-experts mistakenly believe that we’ve figured out interoperability because they keep hearing about FHIR and APIs?

That definitely happens. People assume that since FHIR is now the designated answer, it is the answer to all of the problems faced. But it’s not.

As HL7, we can only take on and mandate solutions that everybody completely agrees to. This is healthcare, so there’s a very limited set of things that everyone completely agrees to. Additional agreements are required. The scope and scale of the agreements required are beyond any single organization. We’re spending increasing amounts of our time investing in collaboration with other organizations to get a seamless process around scaling up agreements and consistency across multiple organizations like IHE that are helping out with the problem.

As long as hospitals buy an EHR and then spend a $100 million customizing it to their workflows, then interoperability is going to be a challenge. On the other hand, the fact that hospitals make those kinds of investments indicates the complexity of healthcare. There is no easy win. There is no easy victory to get interoperability with some kind of tick mark against it. It’s an ongoing process that we’ll be going through for a long time yet.

It seems like every EHR vendor has at least some customers exchanging information with the EHRs of other vendors and now CommonWell and Carequality are connected. Can product shortcomings still be given as an excuse for lack of interoperability?

The vendors work really hard, and from my perspective, the vendors are committed to making patient data as easy to move as possible. On the other hand, the vendors basically fight with their old legacy code bases that are extensively customized and very had to work with. That’s the nature of any mature software product. I think that if I was a consumer, I would be unhappy with where they are, rather than if I’m an engineer looking at their problem. It’s kind of a challenge for the vendors.

But increasingly, as I observe the space, the challenges are with the providers. To what degree do the providers want to share information? To what degree are the providers prepared to standardize their record-keeping practices and their clinical practices to make it easier to exchange data and to transfer patients seamlessly? Not many of the colleges really understand that problem. I would like to call out the American College of Obstetricians and Gynecologists, which understands the problem very well and has very standardized record-keeping practices on paper. That puts them in good stead to get interoperable.

A lot of doctors I talk to think about this as a technology problem, but it’s not a technology problem. It’s an information problem, and so technology can’t solve it. It needs clinicians to make clinical agreements in order to get clinical interoperability.

There’s one more thing I’ll say, which is that interoperability is not a binary thing. We get a degree of interoperability. We can routinely exchange patient summary information. But seamless transfer of care will require a deeper agreement. We’re not there yet. We’re working on those as a community. But I believe that increasingly the load will move away from the IT side or the technical side to the clinical side as time progresses.

Efficiently accepting patient information from an outside source requires placing it into the receiving clinician’s workflow and being willing to use information that was entered elsewhere. Not that we need another interoperability frontier, but is figuring those issues out the next one?

The trust issue is really important. I’m glad you brought it up, because increasingly as I look at projects around the world, the question, is who trusts who and why? A lot of the complaints I hear from patients about poor record-keeping actually comes down to no established trust framework. If the patient provides you with a written statement concerning their medical history and you read that, are you liable for not asking them verbally? Can you rely on that written statement? If you get a written statement from another institution, can you rely on that? The interplay between trust and liability is something that we’ll have to revisit as a community and make that a fundamental part of our interoperability considerations.

What could I do as Provider A if I find that I’m regularly receiving incorrect or unreliable patient information from Provider B?

Looking around the world, I routinely hear that more than half of patient records contain wrong information about the treatment history. Some of those are really, really wrong, and you can easily find examples of that in the media. Surveys that I’ve seen show that it’s more than half the records contains something wrong, and yet we make those available to the patient without any consideration for what a patient should do if they look at it and say, that’s not right, I’m a guy, so I don’t think that a pregnancy test was actually performed. Life’s a bit more complicated than that, but what do they do?

You asked the same question about providers with each other. There’s one organization working on the policies and technologies associated with this, which is Carin Health. But we should start moving towards a culture where it’s a professional obligation that if you share your records with somebody, you have an obligation to have some sort of error detection and correction process running so that your records can be corrected. But in today’s environment, we’re a long way away from thinking like that.

What has been the impact of Apple exchanging information with EHRs using FHIR?

There’s certainly discussion happening around Apple in particular, but more generally patient access to information and what kind of difference that will make. Obviously that was a subject of the keynote at HIMSS. Apple brings a particular sharpness to that debate because of its global consumer reach, the style of its consumer reach, and the potential for Apple to disrupt health in the way they’ve disrupted other industries. I certainly hear discussion about that. Some people are wildly in favor of any disruption. Other people are very much not in favor of any disruption. Some people are concerned about what a consumer company like Apple might do.

My perspective is that getting patients their data doesn’t really make much difference to patient satisfaction or behavior, because it’s all historical data. What makes a difference to a patient is the services that you provide. You need data to support the services, but it’s the services that matter. As long as healthcare services are fundamentally delivered in the flesh in the physical world, there’s a limited degree to which the consumer electronics companies can disrupt health.

In order to provide substantial healthcare services, you have to put people on the ground. That raises all of the classic “how do you manage healthcare” problems, for which I don’t think there’s any magic bullet. I think that their impact will be significant, but ultimately limited by real-world constraints.

Joe Biden and Seema Verma have recently expressed disgust that they, even as high-ranking government officials at the time, were unable to get the medical records of their relatives, and Verma in particular seems outraged. Do you think the government sees its role now differently than it did originally?

It has become more clear across the industry that what we have is not a technology problem. We have a business and an information problem. The government laid down a whole lot of money as far as stimulus, partly to spend money — which it did effectively — and partly to move past the technology barrier to the information barrier. Aneesh Chopra has told me that what happened was relatively predictable. We’ve now solved the technology problem. We can focus on the business and the information problems, and here we are doing that. The NPRM focuses on cleaning out the technology problems and moving the business and information problems to front and center.

But as the government, the levers that you can pull have limited effectiveness. That’s even true in autocratic countries. I was in one country where they showed me that certain things were happening in a particular way. The next day, I would meet with the programmers. They would say, “This is how we do it, but don’t tell the bosses, because they’re not allowed to know.” The levers that you can pull as a policymaker and a money-spender are a lot more limited than people believe. At least the US government is acutely aware of that, much more so than other governments I deal with.

Nothing leaps out at me as any quick solution here, so since the NPRM is marginal improvements being made over time, we can look for improvements. I’m particularly hopeful that we can solve the access to healthcare records problem through thoughtful change. I already saw that happen with vendors. When I started dealing with health information exchange, vendors were suspicious about exchanging patient data. They saw that as a business threat. Now when I deal with C-level people at the vendors, they’re all like, “Well, why wouldn’t we do that? We can’t not do that. It’s part of our business. It’s a business opportunity.” Whereas if I talk to providers, I see providers very much being, “Why would we do that? Why would we spend money doing that? Isn’t that a business threat?” It’s about making that same cultural adaptation to their thinking.

That’s the key thing that we need to chase — the understanding that exchanging patient data with the patients is a business opportunity, not a business threat. But it’s a cultural transition that needs to be bedded deeply through the provider before the provider is ready to see healthcare as a different kind of business model. There are a number of institutions around the USA that are pushing that as hard as they can. Hospital in the home, seeing the hospital as part of a wider network, the whole ACO thing is pushing that. There’s a bunch of things happening, so I’m not particularly pessimistic about it.

Does anybody still care about Blue Button?

There’s a really active community around the new Blue Button work that CMS is doing with FHIR. The FHIR community is picking up and processing the data. There certainly is interest in cross-correlating data from Blue Button with data from the Argonaut interfaces that patients can get, and creating a market in that space. The White House is interested in that. It makes a lot of sense to try and leverage some efficiencies out of the system by cross-correlating payment data and payment efficiency data with individual healthcare data.

That’s the logical place to look for where you, as a funder, could seek to provide more efficiencies in the healthcare system. In the end, the providers of healthcare are not motivated to perform systemic repair to healthcare. It’s the funders who are motivated to perform systemic repair. That’s an important part of the overall picture.

HIStalk Interviews Cedric Truss, DHA, Director Health Informatics Program, Georgia State University

Cedric Truss, DHA, MSHI is director of the health informatics program and clinical assistant professor of Georgia State University of Atlanta, GA.

Tell me about yourself and your program.

I’ve been at Georgia State since August 2017. We offer a bachelor’s of interdisciplinary studies and health informatics. With that program, we partner with the College of Business, so students take courses under the College of Business and within the College of Nursing and Health Professions.

A reader who ran across your students at HIMSS19 said they were engaged, asked great questions, and were enthusiastic. How would you describe their participation? What impressions were they left with?

I’ve gotten a lot of great feedback from some of the students. For some, it was their first time going, Some went last year in Las Vegas. They enjoyed both of the conferences. They said that they were able to connect with some of the companies and to talk with them about some of the things they have been learning in the program.

For instance, we talk about all of the EHR companies throughout the program, so students talked with individuals from Cerner, Epic, Athenahealth, and Allscripts. They were able to get feedback from those who are actually doing the work and to see how it applies to their learning in the program.

How do you cover the theoretical parts of informatics while also exposing students to the real-world aspects that they saw at HIMSS19?

We have a curriculum that’s set around the different areas of what encompasses health informatics. Throughout those different courses, we talk about the theory of why things are the way they are and how to actually make them work in practice.

We have a local Georgia HIMSS chapter and individuals come in to the program and talk to students in the different courses. They explain how what they are learning is applied. This past year we started doing something new. We’re participating in the academic organization affiliate program that HIMSS offers, so we provided all the students with memberships this year. This was the first time that we’ve done this and it is a success, so we will continue doing it.

Were students surprised at the size of the conference and the level of activity around the industry?

Yes, they were, especially for those for whom it was their first time going. I’m glad that it was in Orlando, because it was much closer. They came back and said, OK, now I know what I want to do, or I can pinpoint it. Being able to see this, I can decide what I really want to do and what I want to go into long term.

Yours is a professional program, where students are required to complete pre-requisites and then apply. What kind of applicants do you typically get?

We mainly get students who know they want to do healthcare, but they don’t want to deal with patient care or have hands-on patient care. That’s the majority of the students that we get. We’ve had some that were in the nursing program, and after seeing what they would have to do, they decided, “I don’t want to do this.” They come check out health informatics and fall in love with it.

We’ve also had a couple of students come from the business school. After looking at some of the CIS majors that they offer, they decide this is a better fit for them and the type of career they’re looking to go into.

What careers do they want to pursue?

A lot of students mention project management and analytics, whether it’s data analytics or performance analytics.

Many informatics programs target people who have earned clinical degrees. How does the science aspect of informatics fit with the caregiver side?

You’re not providing direct patient care, but you are providing patient care. You’re making sure systems are working properly so the caregiver or provider can provide you care. If it’s a nurse or a physician at Clinic A but you’re going to Clinic B, that provider can go into the system to see what you have had done, be able to provide the care that you need, and not do something that’s unnecessary, like maybe give you another vaccination that you’ve already gotten or diagnose you with something that you’ve already been diagnosed with.

You’ve worked in different parts of the industry. Is the academic setting different?

[laughs] It is completely different working in academia versus working in the industry. I did enjoy the industry. I loved it. I don’t get to participate as much now in the industry, but I’ve been able to develop new partnerships with those who are in the industry so I can create the pipelines for students to talk with those individuals who are practicing, do internships at these organizations, and even gain employment at these organizations after graduation. It’s been a great fit for me here in academia.

Is there a recognition among your students that Atlanta is such a stronghold of health IT?

There is. We have a lot of health IT companies here in the state of Georgia. Actually, Georgia is considered the health IT capital. A lot of the students are aware of what’s here and the many different opportunities that they can have. We have a lot of health IT startups here as well. That makes the area stand out quite a bit. It gives students an opportunity to say, if I go through this program and I have this idea, I can have my own startup here as well.

How do your students view their future work life differently than the generations that preceded them?

A lot of them are wanting to do different things. Some of them would like to develop their own business. Some of them are interested in traveling and consulting.

I have a master’s in health informatics, so when I went into that program, my idea was that I wanted to be a CIO. But once I got towards the end of that program, I decided that’s not what I wanted to do any more. The opportunities I have had expanded my knowledge and my interest in different areas. The students see what I’ve done and talking with them gives them an outlook that they can do many different things, whether it’s to start their own company, work for other organizations, or travel and be consultants.

Your doctoral dissertation was on hospital ransomware attacks. What are your takeaways from that?

A lot of hospitals were not focusing on security when they were implementing the EHR. I think they figured that they were covered since they had software and a vendor that potentially had them protected from all of that. But I think they need to take steps and have their own policies and procedures in place to prevent that from happening.

How could someone get involved to help your program?

They can go to healthinformatics.gsu.edu. There’s a lot of information on there and it has some contact information as well. Or if they want to reach out to me directly, ctruss@gsu.edu or 404.413.1222. They’re welcome to call me directly and we can discuss options.

HIStalk Interviews Mike Mardini, CEO, National Decision Support Company

Mike Mardini is founder and CEO of National Decision Support Company of Madison, WI, which is part of Change Healthcare.

Tell me about yourself and the company.

I’m a healthcare IT veteran. I’ve gone through three companies in the utilization management and documentation space. We were acquired by Change Healthcare about a year ago.

How will the acquisition change your business?

We had been working with McKesson for two years and they were acquired by Change. We had a good relationship. We knew what we were getting into when the conversation about them owning us started. We knew the people and we knew what the synergies were. We lived together before we got married. That was a big advantage, not only for us, but for them, too. It happened the right way.

It’s content integration and connectivity to impact care. To share data between providers and payers. A lot of assets come together.

How do you balance the big picture of growing the business, raising money, and considering who might acquire you or who you might acquire, all while you are still running the company day to day?

I’ve done it three times and I’ve asked myself that question. Each time was a little different. The first time was the first time. The second time, the strategic buyer was different. But it is a balance. You have to be true to the company and the company’s mission as opposed to a personal type of mission.

Some would say it was harder or easier for me since I never raised money. I never had a bank or a VC dictating what they wanted out of it. It was always personal. Whether it’s running the business or finding a partner, you’re in it every day. You have to be true to the mission of the company and to evaluate how the company is better off, whether it is run independently and we keep on going, or whether we’ve found the right partner to advance the mission. It becomes easy.

Change wasn’t the only one that wanted to us. From the day that we got started, I would say inside of a year, we were courted. We found the right partner.

CEOs have told me that instead of the champagne corks flying once the deal was done, the due diligence was like a colonoscopy and then it was second guessing about whether it really is the right partner, the right price, and the right thing for the company and its employees. Is it hard to balance the negatives and positives of multiple offers?

It was a lot easier this time around than the other two times, whether it was experience or that we had been working with them for two years. It is difficult. It is the colonoscopy. It’s all of that. But this time around was a lot smoother. We knew what to expect, we knew the people, and everybody’s heads and hearts were in the right place.

How hard would it be for a health system to set up and maintain ordering appropriateness checks on their own?

It’s a huge project. They all have a few dozen alerts and advisories. When we install our imaging product, it’s 15,000. Maintaining and managing with native EHR tools is a huge task. That’s why they only do dozens. All the content is managed locally.

Governance is an issue. Tracking the impact and the effects. It is a huge undertaking for sites to do it alone. I’m not sure they even realize how big the problem is. But as the market starts to evolve, they’re starting to ask all the right questions. We want an enterprise partner. We want to understand your analytics. We want to understand all the components, not just whether you put this alert in my EMR.

How do doctors react to that extra level of review or entry that is required to ensure clinical appropriateness?

The docs who are complaining about alert fatigue are primarily correct. When you install your EMR, you have people putting all these alerts. There’s not a lot of thought that goes into it, and even if there is on the front end, there’s not a lot of thought on an ongoing basis. They’ll add five alerts, then two years later, they add another five without taking a look at the original five. A doc does something in the EMR and three boxes pop up with kind of related, yet unrelated alerts. All they do is X through it. There’s no response, there’s no impact, it’s just these things that pop up and they pop up all the time. Nobody says anything, because they’re just X-ing through it.

Thoughtful implementation of guidelines to where they really have an impact, and putting them in place where we’re using the data from the EMR to fire guidance when it’s appropriate. When the end user connects, you understand what the value of it is.

That being said, we still see see doctors who don’t want to see them because they don’t want to see the EMR. They don’t even want to work inside the EMR. There needs to be an improvement in the thought process and the implementation of these advisories to ensure that they’re optimized so we’re not wasting people’s time.

The “revenge of the ancillaries” must play a part, where anyone in any department who wants to collect more information or make their own job easier dumps a new documentation requirement into the newly installed EHR. Is it easier to sell the idea that your recommendations were created by the societies to which those physicians belong?

It all depends on the use case. Sometimes the information is from societies. Sometimes it’s a local rule that a facility wants to implement. Sometimes it’s a payer rule. We try hard to make sure that the guidelines that are actually put in are relevant and respected by the end users.

Imaging is particularly hard. We took on the absolute hardest part of it. An entire service, in some cases 3,000 orderables, 7,000 clinical reasons for why you would want to use those 3,000 orderables, as well as variants used by every specialty in healthcare. It’s not something like, let’s put an alert in there for blood management if the patient’s hemoglobin level is above seven. Everything that we do beyond imaging is much easier for us to hit the target.

Why does CMS keep pushing out the mandatory date for implementing advanced imaging appropriateness rules?

This next date is set in stone, short of a big lightning strike. But I think the market is constantly making CMS aware of just how huge this implementation is. Everybody orders imaging, so they are communicating to CMS that it’s going to impact everybody. They’re getting a lot of push-back. They’re getting a lot of blowback from the market. They want to get it right.

It’s not just that they pushed it back, they have refined it, too. It is not all imaging, it’s certain clinical scenarios. But beyond just that, it’s figuring out how the data gets on the claim forms. There’s a whole process, not just on the provider’s interaction with CMS, but how all this data is going to flow and how they’re going to keep track of it all.

Do I think that they could and should have gotten this done faster? Yes. Am I surprised that it has taken this long? No.

Hospitals get paid well for imaging that best practices say it is inappropriate. Are they interested in ensuring the appropriateness of imaging until CMS forces them to?

That is almost the norm. They want to use it for the stuff that they’re at risk for, but they’re not as excited about it for the stuff that they’re not at risk for. We have seen that.

But the market is moving in a different direction. As the risk shifts to providers, this concept of a standard of care and making sure that there is no waste becomes tantamount. Not just to patient care, but to profit as well. As the risk shifts, everything looks like a DRG. Everything looks like a bundle. We are starting to definitely see a shift in wanting to adopt more and more as this risk shifts. They start acting like payers.

How is Choosing Wisely, which is endorsed by Consumer Reports, being implemented and what results are we seeing?

It’s another set of criteria. Some of it is really good. Some of it is impacted by evidence. The single greatest thing that Choosing Wisely did was create a market awareness that it’s workable to put guidelines in place to impact decision-making. It’s possible and it should be put into place. It has created an awareness.

Many of the Choosing Wisely guidelines are obvious. There’s no debate on them. So it has done a great job of creating an environment where the market is willing to accept putting guidelines in work flow to impact decision-making. The guidelines themselves are good, some better than others, but the awareness that it created is the impact that it has had.

What causes the gap between what a competent practitioner wants to order versus an insurer or hospital that thinks they need to tell them they might be wrong?

There is new data out there that docs may or may not be aware of. The average CME credits that docs get every year can’t begin to cover and keep docs updated with the latest knowledge. One of the points of implementing an EMR is to solve this gap in data. This ability to shed a light to docs on data that is available that would help them in their decision-making. I don’t think anybody could reasonably argue that doctors can’t benefit by being made aware at clinically relevant times that guidelines out there are proven or should be followed. It’s not for every case, but this is science, and information is being found all the time.

We talked about how risk shifts. Let’s go to the extreme and say you have a full-risk model on a provider’s side. Now, when a third part is paying, it’s the third party’s money and they are trying to save on unnecessary testing. Once the risk shifts to the provider, the issue is reversed. How do we prevent the provider from cutting corners? How do we prevent the provider from doing things to save money? It’s not based on bad things or evil or greed. It’s about keeping the lights on.

The only thing that protects providers from liability around cutting corners is to reduce variation in care, to establish a standard set of “this is what we do in this clinical scenario.” It doesn’t mean that somebody can’t veer off of it if there is a variant that exists. But it’s a standard that everybody follows. That ultimately will have to happen to give the provider not only protection from liability, but credibility. Why should the same type of patient with the same scenario walk in and get two different protocols?

Do you have any final thoughts?

I want to go back to the synergies with Change Healthcare and what we’re actually doing here. NDSC came to the table with a content management solution that is designed to deliver provider-focused guidelines seamlessly integrated into EMRs. In a standard way, extract data, calculate that data against guidelines, and then send that clinical data wherever it needs to be sent. We have a large provider footprint and success in the market. Change brings a host of criteria through its InterQual asset, a dominant product in the market that is used by health plans. They also have advanced business intelligence, a large investment in AI and machine learning labs, and a very large network of payer connections with a whole host of claims information.

We are working together to close the loop on delivering guidelines into the physician workflow, then being able to share that information with payers or whoever is financially risk to insure that the right things are done and to mitigate waste.

HIStalk Interviews Guillaume de Zwirek, CEO, Well Health

Guillaume de Zwirek is founder and CEO of Well Health of Santa Barbara, CA.

Tell me about yourself and the company.

I founded Well almost precisely four years ago. My background is not in healthcare. I started my career as a classical musician. Then I worked at Google for four years, then afterward at a big data company that we sold to Amazon. I started a healthcare company because I found myself in a hospital one day and I was just so frustrated with my experience.

Well helps patients and administrators break free of antiquated communication practices. We provide a single command center that connects the many tools they use, transforming everyday interactions between patients and providers.

How can we be sure that hospitals will think about what the patient needs and wants instead of just blasting out self-serving, generic messages that focus on whatever benefits the health system’s bottom line?

I founded this company because I was disturbed by the amount of robo-spam that existed in healthcare. When I was at Google, I saw a transformation from web to mobile apps and then from mobile apps to messaging. That was happening right around the time I was leaving. 

My experience in healthcare in 2015 was precisely what you are describing. Getting four to 17 messages, all saying the same thing that I can’t respond to, with no human on the other end. My only recourse is to call and wait on hold for 17 minutes. That to me is not customer service.

This is an industry that takes up the vast majority of GDP. On average, Americans spend $11,000 a year on their healthcare. A lot of that goes to insurance companies, but you would expect a bare minimum level of support in that environment. One thing I love to tell my team is, pick your favorite retailer — Nordstrom, Lululemon, you name it. Imagine if they were guaranteed $11,000 for every customer that walked in their door. What would they do? How would they treat their customer?

That’s how I like to think about healthcare, because I’m not from this industry. This is my first time in this industry. I encourage healthcare systems to think bigger and to go beyond the status quo. In an era where everyone is talking about AI, machine learning, and automation, we’ve gone in with a totally different approach. You have a phenomenal staff of people at your health system today. They just need the tools to be able to speak to your customers more effectively and make them feel human. It’s really concierge care, but in a way that is much more efficient for both parties involved.

My experience is that providers like to put up self-serving technology walls as a scalable alternative to paying humans to be available, so that if they can make money sending out robo appointment reminders to the potentially unruly masses without hiring people, that’s all they will do. How do you sell them on the idea that it’s OK to allow customers to speak with an actual human?

The problem is that the tools and techniques that are being used today aren’t effective. Look at the portal’s adoption rate across the industry. It’s abysmal. Ask every leading healthcare IT company about their numbers and what engagement looks like with patients. It’s not pretty.

When I was working at Google, my success and failure metric was, will a billion people use this? I was thinking about things on a different scale. I would have gotten fired for having 10 percent of people engaging with a release that I made. That to me is the framework that healthcare should be thinking about when they’re thinking about technology. 

The reality is that you’re only going to engage people when you treat them the way they want to be treated. For texting especially and for messaging, I was seeing a very disturbing pattern. I didn’t want texting to become the new email.

For me, that meant putting humans behind the scenes. An even more important piece was connecting all the pieces. I’m going to divert from your question a little bit, but I’d like to speak to a trend that happened 15 years ago with the EMR and the EHR. This concept where health systems had bought a lot of best-of-breed technologies and all the data was sitting in different silos. The EMR comes around and all the data comes together in one place. Obviously the government fueled this, but there was a deliberate effort by health systems to piece everything together into a central database. Epic and a bunch of others did a great job here.

When I talk to health system executives, I give the same pitch for communications. We’re in a period in time where customer loyalty, customer retention, and building a long-term relationship with patients are critically important. You will never be able to do that if you have 100, 200, 500 different healthcare IT vendors that are all trying to communicate with your patient independently.

I was talking to a health system executive three weeks ago who told me she has 1,000 vendors. One thousand. She did a journey map of her patients, and there was a situation where a patient can get 17 appointment reminders coming from different systems. That’s because the systems aren’t playing nice together.

A big part of this is the educational piece. My pitch to health systems execs is think about communications the same way you thought about data 10 or 15 years ago. Everything needs to be routed centrally. You need to have live agents on the other side to help patients when there’s a need for service recovery.

Health systems like the idea of patient engagement even if they don’t fully understand or embrace what it means. Are they talking to patients about what they want and how they want to receive it?

I’m encouraged by the fact that over the past few years, this position of chief patient experience officer or patient access has become pretty prevalent across health systems. I’m encouraged by the fact that health systems are hiring leaders from outside of healthcare.

Product design and customer research in healthcare is probably lagging behind other industries. A lot of that has to do with the fact that healthcare has acted a lot like a monopoly over time. It’s hyper-local. There might be only a few health systems. The insurance companies control the patients, where you go wherever your insurance company pays. A lot that is changing as patients pay more money out of pocket.

But healthcare for the longest time has had the makeup of a monopoly, just like cable companies and the government. Which is why when you look at customer service ranked by every industry, those are the three worst. They all have monopolistic tendencies.

As someone coming into healthcare from the outside, did it surprise you that unlike in nearly all other industries,  we can’t really define who our customer is?

I’m fortunate that I wasn’t from healthcare and came to the industry with open eyes. I’ve learned a lot. Healthcare is complicated, and for good reasons. There are nuances with patients. A mother with three chronic conditions in a rural area is going be very different than a high-tech Silicon Valley yuppie. There’s a lot of merit to healthcare being more complicated. It is a really, really hard challenge. 

We’re still in the early days of figuring out what a patient engagement strategy means. Health systems are thinking through individual problems. Let me tackle scheduling and registration, eligibility, or telemedicine. We should be taking a step back and thinking about how we can help patients of all these different backgrounds navigate their unique patient journeys. That’s where it comes back to communications for me. That’s where I’ve been laser focused over the past four years.

Is it difficult to get that rational argument heard above all the noise that tends to buzz around healthcare IT?

That’s one part of it that is sad. The most effective way we’ve found to sell is come in and rip and replace legacy systems, the robo-dialers and robo-spammers that every health system has today that send out those appointment reminders that patients love to hate. Then, hopefully, to use that as our Trojan horse to start developing a strategic relationship with the executives and help them understand how they can map out the end-to-end journey, put agents behind this, and offer an unparalleled experience. But that’s the hard part. It’s unfortunate that that’s the way in.

But I’m also pragmatic. I realize that this is a complicated industry with a lot of competing initiatives. Every health system is doing a double Epic upgrade and and CMS is changing their rules left and right. I understand the nuances and the complexities. It was definitely a surprise for me, and one of the sadder things for me, that we have to start there and I can’t start with the full package. I can’t start by implementing this comprehensive, end-to-end solution that would change the way patients experience healthcare. 

It’s baby steps. The jury is out over the next two to three years whether we can get people from that better robo-dialer experience to a truly integrated communications journey for patients.

In the absence of a chief experience officer or chief patient officer, who makes your case internally?

It depends on the health system and where the pain is felt the most. Sometimes it’s IT that is so frustrated with the way that their systems run today. In our world, it’s batch files at night that sometimes go wrong. Patients get the wrong messages and they end up filing support tickets and waiting three weeks. That is when IT feels a lot of pain.

Sometimes it is operations. You’ve acquired health systems, brought on new doctors, exited doctors, and you’re having to manage this entire operational side that is just becoming too time-intensive with existing technologies. That is typically where we are selling.

What is more interesting to me as we move towards risk is thinking about how we could potentially sell on the financial side, to the CFO, to the CMO, to the CNIO. People who realize that keeping patients out of the ED, keeping patients healthy, keeping patients adhering to the protocols that they want them to has long-term impact on their bottom line. That’s where I’d like to see things go. The message will resonate more. But we are still trying to figure out how to sell our message to that group.

How should a startup work with an accelerator or incubator?

You have to go in with a clear goal and objective. We went through an accelerator that was done in partnership with Techstars and Cedar-Sinai. When we accepted the offer to join that accelerator, our goal was to rip and replace their legacy reminder vendor. That was my only goal, my team’s only goal, for the four months that we were there.

We knew that if we succeeded, it would have been worth every minute we spent there. If we failed, we would have learned a lot about how to sell into healthcare, large health systems, and the nuances of workflow. We were successful, but even if we hadn’t been and we had learned those lessons, it would have been time well spent and we wouldn’t have been stuck in this endless pilot phase. I recommend not doing free pilots.

When it comes to accelerators with health systems, I’ve been disappointed to see some of the new accelerators that have come out that try to charge startups money to join. It’s so hard to start a company and be an entrepreneur, especially a first-time entrepreneur like myself, and if we’re going to encourage innovation in healthcare, we need to encourage companies to come to our health systems and spend time with us. We should pay startups if we can. If we want a pilot of their technology, we should pay them, because it costs a startup money to get something running.

The most important thing is that they learn, and they learn quickly, is that the killer of all innovation is time. You can’t buy time. You can’t make time. You have to move as quickly as possible.

We say in health system IT that nobody in the organization is empowered to say yes, but everyone is empowered to say no. Do you find that you need someone to go to bat for you?

It is better to get a quick no than a maybe. I learned this in raising venture capital money. I’ve raised over $14 million and I learned this lesson the hard way many many times. It is way, way better to get a no than it is to wait for months and months and months for a maybe.

The way we did it specifically when we went through the accelerator is that I just asked for meetings. I had a list of 56 practice administrators who had some sort of decision-making authority over the system they had in place. People are normally happy to introduce you to other individuals, especially entrepreneurs and people who are trying to introduce innovative technology. I went into those 56 meetings with an open mind, but a very very clear goal. I got great feedback and refined my pitch, and at the end of the day, I had 50 people who said, I would pay you for this. 

I went to the CIO of this health system and said, I’ve got a bunch of contracts. I think you owe me a few million dollars. What do you think? And I got three pilots out of that. They paid me for the pilots, which was fantastic. But getting to no is sometimes a much harder feat than getting to yes, and it’s just as important.

Silicon Valley types often think they know everything and roll their eyes at any industry that they think is not using technology optimally. How did you develop an ability to avoid talking down to healthcare people in a way that would have made them less likely to want to work with you?

I had my foot in my mouth a few months into starting this company. I was trying to get into this accelerator and they thought we were blowing smoke around integration. I had never integrated before. It sounded really easy. I talked a really strong game around integration. They gave me a second chance to come in and have some humility, be honest about what we knew and what we didn’t know, and where we needed help. I’ve carried that lesson with me every single day since that experience, and that was almost three years ago.

At the core, what keeps me honest is that I’m a patient. All I want is to make things better. I want going to the doctor to be as easy as meeting up with a friend for coffee. I recognize that there is way more complexity than patients ever realize. If I can seek to understand that complexity and partner with health systems to figure out the right solution to making that seam invisible and frictionless to patients, then that’s a win. It doesn’t matter how long it takes. I just need to find the right partners who are willing to get creative and co-develop with us.

That’s where I’m having some of the most fun. Learning with health systems, understanding the challenges, getting curious, and at the end of the day, just trying to make the experience of healthcare something that’s as enjoyable as calling an Uber.

What are the most relevant lessons you learned while working for Google?

There are two lessons that came from the company after Google. I was at a company called Graphiq that now powers a lot of the technology behind Amazon Alexa. The founder there is Kevin O’Connor, a serial entrepreneur. He founded a company called DoubleClick that runs most of the display advertisements on the Internet. 

I learned two concepts from him that I’ve carried with the company. The first is the concept of test-fail-learn, test-fail-learn, test-fail-learn, test-succeed, and then scale the crap out of the things that work. We do a lot of testing. We are very, very focused on analytics. We want data from our customers. We want to give them the data we have. When things aren’t working, we want to pivot.

I’ll give you an example. Early on, we thought that we could launch a health system-to-patient communication solution and also launch a clinician messaging solution at the same time. We failed miserably. I realized within two days of launching a solution that that was such a hard and complicated problem that there needs to be companies dedicated to that solution. Companies like Vocera and TigerConnect do that. That’s just one example of me learning and the test-fail-learn, test-fail-learn mantra.

The other one is this concept of scalable opportunities. Looking at the market, thinking about the things that really excite us but that we don’t really know how to solve yet, and assigning people to those initiatives just so that they become experts in them. As we figure out ways that we might be able to plug into these trends, testing solutions. For us, those are things like the payer landscape and value-based care. There are seven other items that sit on our whiteboard that no one’s actively working on, but we have one person on the team dedicated to thinking about them. One day they might find their way into our product and into our solution. But they are very much pie-in-the-sky ideas, scalable opportunities that we might choose to introduce to our company one day.

As a healthcare newcomer, what did you think of the HIMSS conference?

There was a lot going on. My heart goes out to anybody making purchasing decisions in healthcare. There are so many choices, there is so much noise, there is a lot to make sense of. In my opinion, it doesn’t look like there are clear winners in any category. Walking the, whatever it is, one mile or two miles of the exhibit floor is a clear example of that.

We knew that we had to have a decent presence at HIMSS for people to take us seriously. We went to HIMSS with two goals, to build vendor relationships and to meet with our existing clients and to meet with prospective clients while they’re all under one roof. I was happy with our performance and being able to achieve those goals, but it is a noisy space. I don’t have any solutions around how to make sense of the noise. I guess as a vendor, trying to be louder and trying to prove more value in a way that people hear who are making those buying decisions.

Do you have any final thoughts?

I’m having more fun than I have ever had in my career, and I’m 12 years into my career. I’m sure you’ve heard this from people many times in the years you’ve been writing HIStalk, but I believe that we are at a juncture in healthcare. I believe that patients feel empowered. I am encouraged by many of the new companies coming into healthcare. I am so encouraged by health systems that are opening up their doors to companies like ours, to help them learn and to help them bring new technologies to market. I am hopeful that investors will continue putting money into healthcare IT and that they will see big successes that keep fueling development in healthcare. 

At the end of the day, my personal goal is to flip the status quo, in which healthcare is in the bottom three industries in terms of customer service. In my humble opinion, it should be number one.

We have a long journey ahead, but there’s a lot to be encouraged by and excited about. It’s people like you, investors, health systems, and frankly, companies coming into the space and even competitors of ours. So I really thank you for taking the time to speak with me and for seeking me out. It’s people like you who are helping drive this industry forward the ways it needs to be driven forward. I’m very appreciative.

HIStalk Interviews Randall, An Anonymous Health System CIO

I invited health system CIOs to interview with me anonymously, knowing from unfortunate personal experience that health systems don’t like their executives going off script to a national audience. Randall (not the interviewee’s real name) offered to spend 20 minutes on the phone with me to talk about what it’s like on the front lines. CIOs willing to do the same can contact me to arrange a fun conversation.

What are the hardest parts of being a health system CIO?

You serve many masters. The administrative area — the CEO, CFO, CMO — each have different objectives, goals, areas of influence, and levels of influence. Then you have your physician population, both from the acute care setting and employed physicians in the clinics. You have the masters of the regulators and dealing with the Promoting Interoperability Program at both the federal and the state level. You have operations, the directors and managers who are dealing with patient care or the revenue cycle or finances for the hospital. You also have another group to deal with in vendors and contractors.

At the end of that, you have your staff. You have a workforce that’s dealing with the same types of pressures you are at the CIO level, but they get it day-to-day in the field. You have to encourage them, empower them, and coach them to deal with that environment. That takes a very special set of people with their goals and their work ethic aligned with the organization to keep them going. Otherwise, they’re looking at it as just an IT job. They probably won’t survive in the healthcare space very long.

It’s a challenge and it’s a lot of juggling, but I chose this industry because it is challenging. It changes and requires you to think on your feet, to plan, and be strategic. It is not a boring job, that’s for sure. It can be frustrating at times, but it can also be very rewarding. You go through these challenges with people who you spend quite a few hours with, do a lifetime of work with, and you can identify with each other on each other’s challenges. You build some pretty strong relationships.

At the executive table, how do you reconcile what everybody wants in making sure that IT’s contribution fits into the overall health system strategy?

That’s the unique position that we are in as IT. We are exposed to all the workflows, especially on the applications side. We know the upstream and downstream effects that changes have. We know the benefits of using a technology, but we also know the downfalls of not planning it out well.

Those around the leadership table have a difficult time. They have to consider the mission and strategic plan while compromising around a single goal of achieving that strategy, but they have their own needs in their departments or with a particular physician.

We talk about flexibility all the time. But we have to set a course and not just stay the course. We have to support each other through those difficult decisions, what might be great things to do that would detract from what we already agreed are our priorities.

In each senior leadership team meeting, I say, here are all the things we’ve committed to. Here are the estimated hours the IT team alone needs. But we’ve already committed more hours than are available over the next six months. Then the CEO starts to look down the list of projects to ask for each one, why are we doing this?

When they start to dig into the projects, they circumvent the original decisions that were made by the VPs to execute on those projects. They are looking to the CIO to say what the priority should be. The other side of that sword is that two years ago, there wasn’t much governance going on in this organization. Senior leadership and directors were complaining, “IT is telling us what to do.”

OK, which is it? Do you want us to provide the guidance or do you want us to just facilitate it? That’s a challenge. There’s a balance there. This particular organization is having a lot of struggles getting into a more formalized initiative and governance process around their projects — not just in IT — and understanding what resources are involved with those. When they make changes, what impact does that have on projects that have already started?

Are executives worried about high software maintenance costs?

I don’t necessarily see that as an issue here. We cover that pretty well during the budgeting process for capital stuff. Maintenance is budgeted. It is a big nut, a large number. The board sees the percentage of operating expense coming from the IT area on things like maintenance continuing to climb, so they are aware of it.

The bigger challenge for this organization on its maturity curve is that when they look at a solution and they’re working with a vendor, it tends to be siloed around just the solution. What about the upstream effects or needs for your system and the downstream effects?

I’ll give you an example. We have a rather old cardiology rehab system that is documenting patient care. It needs to be replaced because it is no longer supported, but they want to interface that information into the main hospital system. But what they submitted for consideration was just the software and the maintenance for just that piece of software. Nothing about the IT hours needed for integration and the cost for the other system to do the integration.

IT ends up becoming the bearer of bad news on every single project for unplanned cost. It’s not just maintenance, but presenting the entire package of everything that’s involved with a particular initiative so that we don’t have any surprises.

Unfortunately, we’re still having surprises. Vendors don’t want to share that information. The sales folks want to close that deal as quick as they can, The standard feedback from them is, “You won’t need any IT support.”

What is good and the bad about having a few limelight-seeking CIOs representing those who just stay home and get their employer’s work done?

The good is that they sometimes expose you to other things that are available. The bad is that they represent themselves as the experts based on experience and most of them don’t have the experience. They are out there interacting with vendors and other industry people who have a particular agenda to address. Rarely have those who are popping up all the time been involved in implementations and dealing with the interactions with the physicians and the staff, both their own staff and the staff in the hospital. They are ego stroking. Hey, look what I know.

For me, it doesn’t necessarily translate into experience, lessons learned, and how I might be able to do that in my particular environment at a community hospital or a large health system. Other CIOs have actually been in the field, but they are few and far between and also in high demand.

I liken them to the chief medical officers that have grown up through an organization. They have a difficult time balancing the days that they’re in the clinic and treating patients with all their administrative responsibilities of the medical staff and administration. It’s a tough job. I always appreciate when those kinds of individuals who have real-world experience are willing to share that information.

The guys that are out there on LinkedIn and all the publications out there, telling you that “this is what you should be doing,” I have to take that with a grain of salt. It’s great to hear about what things are available out there, but sometimes they have to bring it back to bit of reality and what hospitals can actually do.

What kind of information sharing is most effective for a CIO who has to work for a living and who doesn’t have unlimited budget or time to self-promote?

CHIME has been a pretty good forum for CIOs to share information, although I’m starting so see it morph a little bit towards what HIMSS has become. I’m hoping they hold the line and don’t go that far. Those interactions between CIOs, one on one and sometimes in smaller groups, tend to be most valuable to me.

Every once in a while, I will reach out on the MyCHIME bulletin board to explain something I’m trying to solve and ask, has anybody gone through this? Some people like to share what they have done and what they have been challenged with, but not in an open and public environment out there like a magazine or something like that.

Is it too late for HIMSS to reel in vendors and is CHIME is too far along the path to do the same? Or is there no inherent conflict between what vendors want and what provider members want?

That’s the hard part. I don’t know that I have a solution for that. Vendor involvement is somewhat of a necessarily evil. Their motivation, no matter what they say, is that they have a business to run. They have to grow. They have to generate sales. They may have a great product, their company may have started off with a great idea and just grew from there, but in the end, they have to generate more leads. That’s the nature of our economic engine.

I find it a really difficult job for HIMSS to do. But at this year’s HIMSS, I was actually a little bit pleasantly surprised by the education sessions that I went to. Vendors weren’t running those presentations like they did in the previous couple of years. It was a little bit more low key with the vendors this year.

CHIME does a pretty good job of asking vendors to establish relationships with CIOs rather than coming in and doing hard sales. They do that through their focus groups, which is a pretty good idea, having five or 10 CIOs or senior IT leaders talking with a vendor about what their future plans are and what problem they are trying to solve.

I’ve been to a few focus groups that involved a solution looking for a problem. But in those focus groups, the CIOs are emboldened by each other being in that room and helping each other out. They give the vendor feedback and sometimes tell them straight up, this isn’t a problem we’re trying to solve. Or they’ll tell them, this is a great idea, but have you thought about it in this area? Trying to tweak or mold their solutions to that particular problem.

A good example from CHIME is that a year or two ago, I was on a focus group with the IBM Watson people. The entire room kept saying, what are you really delivering here? IBM Watson basically ignored all the feedback, at least based on the public perception that’s out there now. They still haven’t delivered. It’s a great idea in terms of what it might hold in the future, but overhyping on the front end doesn’t really help them. It destroys your reputation when you can’t deliver.

Health systems claim to embrace innovation, consumerism, and value-based care, but they still use fax machines, offer a poor visitor experience, and make a fortune by cranking out fee-for-service work. Is there a difference in what hospitals say versus what they are motivated to do?

Value-based care is BS. You are talking about trying to get to a subscription model with a patient. If your clients, your patients don’t want that and don’t feel a need to do it, then you are forcing a business model on them that won’t work. They don’t want it. They don’t feel the need for it. They just expect delivery of high-quality care episodically when they are ready and they need it. I don’t know that a hospital can solve that problem.

Hospitals and clinics can become more consumer-centric. As an administrator or an IT person, when you go to a clinic or hospital, what do you expect as a patient to be delivered that you might get from other types of industries? You would like to be able to do things on your smartphone. You’d like to be able to schedule appointments online. You’d like to be able to get your medical records freely and easily.

We have to back away from the regulatory demands and the billing demands and get on the front end of the consumer. Because in our environment, in our US of A, everything is based on capitalism, and he who builds the better mouse trap is going to draw more customers.

I don’t know how we will ever make that transition to value-based care unless you have a single-payer system, which I’m not an advocate of. But I don’t know how else you can do that. You are forcing patients into having to become subscribers to a healthcare service rather than episodic paying for what I need, when I need it. That’s my opinion, but the current environment pays my paycheck and I have to operate within it.

HIStalk Interviews Michael Schmidt, Managing Director of Strategic Innovations, Orlando Health

Michael Schmidt, MBA is managing director of strategic innovations at Orlando Health’s Strategic Innovations program in Orlando, FL.

Tell me about yourself and the organization.

I’m the managing director of Orlando Health’s Strategic Innovations program. My responsibility is to coordinate our internal and external innovation efforts.

My colleague Callie Patel from Healthbox and I just presented at HIMSS19 on developing internal innovation competencies. We did a case study of Orlando Health’s journey over the past two years in going from having no formal innovation program – no structure, resources, or any of that — to having a formalized program where we run an annual internal incubator. We have various pathways for different types of projects. Then we have a venture fund to invest in external healthcare startups that align with what we’re trying to do.

Many health systems are experimenting with incubators, accelerators, and innovation funds. What are they trying to get out of that, and what have we learned so far?

There was a quote that was a theme during HIMSS that if you’ve seen one innovation center and program, you’ve seen one innovation center and program. Everybody’s trying to tackle similar concepts and strategies, but the execution looks pretty different. The more I’ve started scan the horizon and look at other health systems, I’ve been surprised how many have a program like this. Maybe not the same setup or focus on internal and external at the same time, but most of the major health systems in the country have moved in this direction somehow.

We might be a little different. First and foremost, our goal with an innovation program is culture change. We’re a $3.2 billion community health system across central Florida and operate at a very effective level, but we have never had a lot of the core competencies that a university hospital system or big hospital system in a large metro area might have. We’re playing catch-up a little bit.

We realized that a lot of what we needed to accomplish was education and acclimation for a lot of our physicians and team members to understand what innovation means to us and why we’re doing what we’re trying to do. Then, how they can play an effective role in that. Secondary to that for now is the ROI on the initiatives. Over time, that will change, but we’ve been trying to focus on engagement with our employees and our physicians.

I credit our partner Healthbox for their structure and their philosophy. Technically they’re a consulting group, but they’ve partnered with us. It’s almost like I added 10 to 12 people to my team from Day One in working with them. We’ve set up a consistent process, a thought structure and philosophy on what types of ideas we are looking for, and the criteria we used to assess those and to decide which ideas advance.

For our internal incubator, which we call the Foundry, we only accept four ideas each year. We would rather have a small number of successful projects than dozens that are stalled out in some different phase of development. We ask our team members and physicians to look for ideas that solve pain points that they’re experiencing. We have criteria that we assess these ideas on. Throughout the entire fall, the application window is open for people to submit their ideas, providing rationale as to what impact it will have internally. Will it save us money, help us consolidate the supply chain, or improve quality?

We look at five facets of that application and score the idea and the innovator across these things. What is the commercial potential? Is this idea eventually going to fit in a market that’s super competitive, or is there a decent-sized niche that we could carve out based on how unique this idea is? How innovative is the idea? Is it a small iteration on an existing idea or product, or is this big-shift, game changer, completely new type of product or service?

We also look at the person who brought the idea forward. Not everybody has the same natural entrepreneurial skills, so part of what we assess is what type of support structure, education, and team we will need for this person to be able to drive their idea forward.

Finally, we look at the potential internal impact and how it aligns with our strategic plan and the pillars of that plan.

We score everything across those five categories. We rank them, and then I have a committee of about 30 senior leaders and physicians from across every major area of the organization. We sift through those ideas that are currently ranked based on those numerical scores and then we start to challenge assumptions. We ask each other what we think will work with this particular idea and try to whittle that down to the top four or five that we’ll end up choosing from to go into the program.

We do things a little bit differently than some of the other systems I’ve seen. This incubator is just for our employees and our physicians. It is specifically designed to develop Orlando Health’s intellectual property. The person who brought the project forward will drive it. They will be in charge of budget, if it gets to that point, and coordinating with the work group.

But at the end of the day, it is Orlando Health’s intellectual property. We will work with them to license it out or sell it. We will pursue those paths before spinning out something as a separate business. Then if it is profitable in some form or fashion, the person who brought that idea forward gets a significant portion of those those royalties.

A number of our key physicians said over the years, I’m working on stuff, doing research, coming up with these ideas, and I have nowhere to take them. I would love for Orlando Health to be the organization that drives this stuff forward. But until a couple of years ago, we didn’t have anywhere for them to go or any support to offer. Now they are excited that there’s a pathway for this stuff.

What kind of employees or physicians bring in ideas and what stage are those ideas in?

A year and a half ago when we first started this process, announced the concept, and opened up applications, we had no idea what we were going to get. We were pleasantly surprised across all fronts. Last year we had just over 60 applications. I would say probably 10 percent of them had a working prototype or very thoughtful design.

The rest were early-stage, sketch on the back of a napkin sort of concepts. That helped up shift a little bit to accommodate ideas at that stage. They need a lot more due diligence and a lot more planning to get to a place where we can start to build prototypes and things like that.

We’ve gotten ideas from almost every corner of the organization. Physicians have definitely been a lot heavier in the mix than other types of team members, and the physician ideas tend to be more developed. Sometimes they have put their own personal funds into developing it just to see if the concept works.

How do you determine which ideas have commercial market potential beyond solving Orlando Health’s problem?

My selection committee helps assess it. We pick people with different types of experience and backgrounds. We have a handful of people here that have worked in early-stage companies and have some of that insight. That’s where Healthbox as our partner comes in. Behind the scenes, they’re helping us guide the whole process, helping us with our criteria to move ideas forward. They also produce some pretty comprehensive research on each of the idea, such as a market scan and competition analysis, so we know what we’re looking at. Then an assessment of the resources the project might need to get each of those ideas to prototype and minimum viable product.

Do you get involved in whatever happens next in terms of actually creating a company around the idea?

We’ve staged it out appropriately to account for making sure that we’re staying on track, that things aren’t getting ahead of where they should be, and that we’re not setting aside too much in the way of funding. Each year, the four projects that go through the foundry process can come back and do a “Shark Tank”-like pitch to our executive team and other senior leaders and ask for a budget for the next 12 months.

We stage it out in 12-month increments to make sure that it’s manageable because these people still have their full-time jobs. Our funding allows them to set aside a set number of hours every week and those funds reimburse their department or practice so that their department is not losing anything with this person working on the project.

Mostly what we set aside funding for is bringing in external resources, whether it’s a software developer or a biomedical engineer to help us draw something out in CAD. We have checkpoints throughout that process where our team, other internal resources that we’ve lined up for assessment, and then Healthbox are making sure that those projects are on the right track and advancing the way we think they should.

But we’ve also said that overall, going through the foundry and getting to the end of that process does not mean that it is market ready. The foundry itself is one of the steps for validation, making sure we can put the idea through the paces. Will it do what we think it needs to do? Does it end up conflicting with other vendors we have or internal resources or processes that are in place? That process helps us understand how this would end up looking if we were to scale it across one facility or the entire organization.

Then if it continues to check out throughout that process, we start looking at who we would likely license or sell this to. What type of partners would be ideal? We haven’t had any projects get to that point yet, but we have a few that we’re starting to scan the horizon.

What does your team look like?

It’s a very small team right now. I feel like a one-man band most days. The senior executive that started this process is essentially our chief strategy officer. His title is senior vice-president of strategic management. Our broader team is responsible for all of the strategic planning and execution across the entire organization and we are tucked alongside that. It’s myself and an analyst who works for me.

But then we have the committee, and then a number of people throughout the organization have expressed a strong desire to partner with us to help the program continue to grow. We lean on a different person across that network based on what we need. What’s helped us be successful in standing this up so quickly is bringing in what I call adult supervision, a partner who’s experienced in this, like Healthbox.

What did you bring back from HIMSS19 that is most applicable to what you’re doing at Orlando Health?

That was my first year going. It is completely overwhelming. It was really hard to take in everything that was there. I almost wish it wasn’t so big.

But it’s fascinating to walk the vendor floor and see who the big players are. We have someone who helps us on our venture fund side and he said, “Start to look at the smaller companies that are on the periphery that have a really small space. When you come back next year, see who’s moved inward a little bit. See who has a bigger footprint. Pay attention to those types of moves.”

We were also looking at broader themes, trying to get a sense of where some of the technology is going, where some of these segments of the industry are going. It is so encouraging that healthcare in general is rapidly changing and the notion of digital health and that entire segment of companies and products and technology has really started to take off.

I sat through a number of presentations on the expo floor where they were demoing. Seeing the way that AI, chatbots, and virtual assistants are starting to impact the patient experience was cool. That was one of the things I took back to our team and relayed.

Patient experience is one of our top priorities this year, to solidify how we deliver a consistently excellent experience. We don’t always have the right tools. Historically we’ve had some silos, where different forms of technology that we had implemented didn’t necessarily talk to one another.

I’m trying to look at things from a 30,000-foot view and figure out where we can start to weave some of this stuff together, to see what’s available on the market that we could plug in and where there are gaps where  we could create something internally that would help us move quicker.

HIStalk Interviews Nora Lissy, Director of Healthcare, Dimensional Insight

Nora Lissy, RN, MBA is director of healthcare for Dimensional Insight of Burlington, MA.

Tell me about yourself and the company.

I’ve been a registered nurse for over 30 years. I started out as a clinician, with the majority of my time spent in the emergency room. I then got interested in hospital operations and working with the operational folks and leadership. As healthcare evolved, I evolved with it and got into analytics, understanding numbers and outcomes. I used Dimensional Insight’s system in three different organizations in three different roles and found that I loved what I was able to do with it. I came on board with the company in 2013. I help organizations understand their information, their data, and to get the right data to the right people so that they can act upon it.

Do health systems underuse nurses and other clinicians in using data to make decisions?

Yes. Our president likes to talk about the “data gene,” which some people have and some don’t. Every organization definitely has pearls — not only nurses, but lab and rad techs who actually understand the global picture. There’s always one person in every department where everybody knows that if you need an answer, you go to them. Those people are usually data-driven to begin with, just naturally.They do get underutilized, or shall I say mis-utilized. They have their regular job, and then when they have a chance, we’ll  have them do reports and stuff like that for us. But some very strong care providers are also analytical and would be helpful in pushing forward the analytics process.

BI and analytics tools triggered a buying frenzy. What was the result?

Like you said, it was a frenzy. Everyone felt like they had to get it. Many people are influenced by pretty pictures, or they go down a path and they’ve got someone who’s caught their interest.

What I’ve noticed in working with customers and in the literature is that sometimes customers take on too much. BI is a journey. When an organization tries to do 15 projects at the same time, it’s inevitable that none of them will get finished. A project gets started. Then it’s like, OK, this is cool, we can use that same tactic over here. They start big project B before finishing big project A, with the same people working on both. Now you’ve pulled them in two different directions and nothing gets finished.

The successful ones that I’ve seen have stayed within the guidelines of their strategic plan. Some people feel it takes too long to get that done, but you need to have a plan, a path you’re going down. Not just say, “We’ve got BI and we can do everything.” Every tool can, but you have take the steps and do it and close the loop before you go to the next one.

I’ve worked in organizations that had four or five BI tools, so they had four or five reporting teams. They still had the same problem — my BI tool says this, your BI tool says that. They never really got together and said, what do we say as an organization?

Does BI get the credit way down the line when the decisions it influenced finally produces positive, measurable results?

I think so. What I’ve seen is that there’s a big fervor at first. Everybody gets it, they see stuff, and they go wow.  But a BI install suddenly provides access to a lot of information. That’s the other “aha” that gets you. We have all this data and we don’t know what to do with it. We had none, now we have too much. How do we core it down to what’s going to be meaningful to us?

That’s where I think the BI tool can come into play, to help us focus on what we need to focus on because we have so much out there. Healthcare is just loaded with data, and more comes in every day. We want to use these complex business rules and these algorithms, but we could have obtained the same answer if we had just used a quicker approach.

Health systems have all this new data, multiple teams, and a mix of acquired health systems and practices using different systems and different terminologies, plus trying to decide whether to centralize the analytics function. Do these factors make it tougher to do analytics right?

Absolutely. It’s an absolute challenge, everything you just said. You might have a hospital organization that has been using an embedded BI tool for years. Then all of a sudden they acquire, or they’ve been acquired. They decide that they don’t want A, or they really want B. Then you have to go through a conversion of what they’ve done. Aside from just the acquisition process, you have to work on linking and cross-walking different EMRs or even the same EMR implemented with different approaches.

I’ve worked in two organizations that had four or five reporting teams. We were chasing our tails. Who do you believe? Who has the loudest voice this month or with this leadership? The people who really need the BI, the operational and front-line people, throw up their hands and say, “I don’t even know what I’m getting any more, so I don’t even care.” You look at who is using the BI and there’s little utilization. The people we’re trying to help don’t even get all the information they need because there are too many competing answers.

I find that the best success is when you bring in not only stakeholders, which is your leadership, but also the people that you’re expecting this data to help. They need to be a part of the process. You can’t just put this together and say, here you go, you’re on your own, take it and run with it. You have to bring them into the process so that they understand the value they’re getting. It’s one thing bringing a BI tool in, but what’s the value I’m going to get from it? Is it just one more report that I have to go through, or will it give me value and make my day better?

My experience is that the people who use analytics the most are department managers and directors instead of C-level executives who don’t even have computers on their desk. Should the C-suite be involved or pay more attention to what data is available and how it’s being used?

I would say that over the last two or three years, I’m seeing more and more C-suite involvement. I have a couple of customers that if the information isn’t available when the CEO comes to work, he or she is calling and saying, where are my numbers? So I am seeing more senior suite involvement.

There are two types of BI – the “how are we doing” numbers for the C suite and then the operational things, which are near and dear to my heart. The things that I had to do as a clinician or as a manager of clinicians. The things that I needed to arm them with. We can give that to them. Before, we would have to go through 15 reports to try to figure it out. It’s making their life easier.

There are so many rules and regulations coming out in healthcare. I have to remember to dot my I and cross my T. Maybe if I had a queue list to tell me that these are the three things I have to worry about, that would make my life easier.

It’s like anything else you do in life. It’s a daunting task if you have a room full of garbage and you have to decide where to start. You have to pick at it and say, I know I’m going to keep the stuff over there. That’s one fewer thing I have to worry about. From a BI perspective on the operational side, they see their page with their three things and they’re all green and they’re good. If one is red, they have to go focus on that. It’s helping them get through their day-to-day operational side.

We haven’t quite gotten the value from BI because healthcare and the operational side of things are complex. When I say operational, I’m thinking about your clinical folks. Was the assessment done in 24 hours? When was the last time case management saw these patients? There are standing operating procedures that are in place that if something goes wrong, we might stop and take a look at it. But generally speaking, it just goes along day by day until the holes in the Swiss cheese line up and you realize you should have been seeing this. But life’s busy in the hospital. We need to provide actionable information to the day-to-day providers so they can prevent the harm.

What new data elements are available for that alerting and trending analysis and how are they being used to impact individual patient care instead of just giving executives a stoplight report?

It’s more the capacity of how BI itself is evolving and how data is being pulled. The old world of BI was SQL queries. Now you’re getting into columnar databases that allow for a faster retrieval and for more data to be viewed at one time. That technology allows you to cipher through millions of rows of data. 

Think about it from a lab perspective. When I was at a healthcare organization in North Carolina, I worked with a clinical pharmacist to identify the five or six high-risk drugs that they wanted to have insight into. Then we got a tickler every time the lab values changed. We added the information to their hourly census, so that when the lab values came in and the patient was on this particular medication, they would see the trend before it got to a critical point. They would see that it’s been rising for the last two days by 0.2 percent each time, so we had better keep an eye on it.

It becomes more useful with the ability to visualize and manage more data at one time. I have another organization whose pharmacists use it to look at critical medications. They bring in over 40 million rows of data to use their work queues to improve their movement from IV antibiotics to PO antibiotics so they can lower cost, improve patient care, and hopefully get the patients out of the hospital sooner than later.

The BI approach uses technology to highlight exceptions to the defined desired values, while the machine language approach would be to throw a lot of data at the system to identify new problems or opportunities that humans have missed. How do those approaches co-exist?

Machine learning has a way to go, in my opinion. Someone still has to feed that machine some kind of algorithm, and it has to know what it’s looking for. Some are more sophisticated and can do patterning and I think that will become invaluable over time. It’s not mature yet, where physicians believe that it shows them what they expect. But it will be an invaluable asset as it continues to grow and as we continue to understand how all the data fits together.

Why have we stopped hearing the most overused term on the planet, “big data?”

Because everything is big data. It was just a catch phrase. I don’t know where it started, and then all of a sudden, it just went away and no one is even saying it any more. This may sound ignorant, but it’s the same thing when we talk about AI and machine learning. What do we mean by AI and machine learning? What concept do people have of that? What are the developer’s concepts? What do its potential users think? It raises the same kind of question as the term big data.

Do you have any final thoughts?

I really enjoy what I do now because I get to work within my passion in using analytics to help providers — who need it more than anybody else – and to help the operational folks with their daily operational process that is very difficult. There’s a lot of expectation that the people on the front line will get things done, remember all these rules, and do all these things. As we move forward in analytics, we will hopefully be able to make that life easier for them and help them focus on getting back to taking care of the patient.

HIStalk Interviews Terry Edwards, CEO, PerfectServe

Terry Edwards is founder, president, and CEO of PerfectServe of Knoxville, TN.

Tell me about yourself and the company.

I started PerfectServe in the late 1990s after spending a few years in a technology company called Voice-Tel, which was one of the early pioneers in interactive voice messaging. At that company, I saw the need to improve communications in healthcare and later started PerfectServe. The company started in managing communications in the physician’s office, extending later into managing nurse-to-physician communication in the hospital and acute care environment while still doing the physician work. We evolved that over the last several years into one of the most comprehensive communication platforms in the industry.

How will the mid-January acquisition of Telmediq, the top-rated secure communications vendor, change your business?

PerfectServe was acquired by the Los Angeles private equity firm K1 Investment Management in the middle of last year. That was part of the plan to get our early venture investors out. They had been invested in PerfectServe for a long time and stood behind the company. We were able to give them a successful exit.

With that, we were also able to clean up PerfectServe’s balance sheet and to gain the backing we needed to execute on a broader strategy. As you and I have talked about in the past, the industry in which we operate is that outside the realm of the EMR, the technologies are fragmented. We started to see this just in the fragmentation of communications alone. But in addition, other technologies that are adjacent to communications could be part of a more comprehensive platform.

We surveyed the landscape and saw the opportunity to consolidate some of the stronger players within our category. Telmediq was at the top of that list. It had capabilities that we did not have, such as in the contact center and call center space as well as in nursing mobility. We thought those would be valuable to our customers. While there’s overlap in what both companies do, Telmediq was doing some things better than PerfectServe, and PerfectServe was doing some things better than Telmediq. By bringing these two together, we believe we’ve created the leading communications platform in the marketplace.

How important is it for a CEO to work with investors who can help take the company to the next level or help it clarify its acquisition and positioning strategies?

K1 is a growth investor. There are different kinds of private equity firms and different business models. Some will find slower growth opportunities with companies that might be growing five or 10 percent a year, then put two of them together and then take out costs and try to drive synergy.

K1 is a growth company where they are looking to invest. They are about building leaders in the category. As they evaluated PerfectServe, one of the opportunities was that PerfectServe could be the cornerstone of a much larger and broader care team collaboration product offering strategy. That led to the opportunity to acquire Telmediq.

We just announced two other acquisitions. Lightning Bolt Solutions, which is in the physician scheduling space, and CareWire in the patient communications space. Our broader strategy is to build the care team collaboration platform of the future. We will do this through both acquisition — and integration of the acquisitions — as well as organic development. That takes capital to do well, which is why we have K1 at the table with us.

Was the death of pagers greatly exaggerated?

[laughs] They are dying a slow death, but there’s a long tail.

Consumers seem to be using phones more often for texting more than for making phone calls or sending email, and now they are using speech recognition to drive that messaging. How is that  impacting healthcare communication?

I’ve been amazed to watch the adoption of texting as a mode of communication. When we started PerfectServe, everything was voice driven. In fact, the first version of the PerfectServe platform was purely an interactive voice response platform. All the communications were voice driven and interacting with the keypad.

We first entered the acute space in 2005. Due to the nature of the platform, 100 percent of the communications we were processing were over the phone, either as a live call or sending a page or text message. The text messages could be as an alphanumeric page or SMS and they were all system generated.

We later introduced our web interface and then our mobile interface. With mobile came texting. We started to see texting rise.

About 18 months ago, we introduced a new user object so that nurses could authenticate in the same way as our physicians. With that, we were able to facilitate bidirectional communication. A nurse can send a text to a doctor via the secure platform, then the doctor can reply. In our newest hospital environments, 90-plus percent of all the communication that’s running through the platform is text, and it is secure text, which has been fascinating to see. It’s convenient and that’s the benefit.

What is being done to make communications part of the overall workflow?

Gartner has classified us in the category of clinical communication and collaboration, or CC&C. They gave it that name to help communicate to hospital buyers that communication is more than just secure texting. Secure texting is a component of a broader communication strategy.

But as we’re looking at this — and I think it’s consistent with how Gartner is looking at this – the clinical communication platform is a core component or pillar of a broader care team collaboration platform. It needs to encompass the communication modalities of secure texting, paging, SMS messaging, email notifications, and voice calling, whether it’s a cellular, voice over IP, or landline. You have to have this omni-channel communications component.

The key to PerfectServe since Day One has been our workflow capabilities. We are automating a communication workflow to make sure that we can connect the initiator – a nurse or a doctor or some other caregiver — to the person they need to reach, who can then take action at that moment in time. Workflow is a component of this.

As you think about workflow, there’s not only the algorithms around routing, but also call schedules. PerfectServe as well as Telmediq built call schedules into our platforms, but they were limited to the schedules specific to a communication workflow. Medical groups, for example, have scheduling needs that are broader than that, that go across the whole workforce. That is where Lightning Bolt comes into play.

These adjacent technologies move beyond communications to staff scheduling, referral management, rounding, and integration into other technologies like alarms, alert systems, nurse call, and interactive patient care. Our vision is to build the most comprehensive care team collaboration platform, either by building or acquiring technologies that make sense to be a part of it, and then integrating with those that are adjacent but outside the domain, such as nurse call.

How have the communications needs of health systems changed as they acquire hospitals and practices?

I don’t think they are changing, but the expansion is enabling them to put in stronger governance structures to drive higher levels of standardization. One of our clients, Advocate Health Care in Chicago, has been a model in terms of saying, these are the parameters upon which we’re going to communicate with you. We’re going to have these minimum standards around fail-safe notification processes and escalation and things like that. This starts to move the organization away from letting doctors do it however they want, which might be might be efficient for them but not for nurses or colleagues who need to reach them.

What do you as a CEO do during the HIMSS conference?

[laughs] It’s usually a pretty packed schedule. I will spend a little bit of time in our booth, and that’s unstructured. But for the most part, I’ve got meetings scheduled, a mix of customer meetings, new prospect meetings, analyst meetings, and sometimes meetings with folks in the financial community. It’s usually a pretty intense time, one of those events that I look forward to, but that I also hope to never attend again.

Do you have any final thoughts?

I’m excited about where PerfectServe is. Not just for me personally or our company, but for our customers. I’ve been in this space for a long time and I’ve seen a lot of things. There’s this bigger vision that I started to see about three or four years ago and it is here now. PerfectServe and our customers have the opportunity to deliver even greater value than I envisioned. I’m excited about that and excited about the future.

HIStalk Interviews Jason Krantz, CEO, Definitive Healthcare

Jason Krantz, MBA is founder and CEO of Definitive Healthcare of  Framingham, MA.

Tell me about yourself and the company.

Definitive Healthcare was started in 2011. Our goal is to be the premier provider and the single source of truth for all data on healthcare providers. In the last seven or eight years, we’ve grown significantly. We have about 320 employees today. We offer detailed information and analytics on every single provider in the US and Canada.

Why did HIMSS sell its HIMSS Analytics business and how did Definitive Healthcare end up acquiring it?

HIMSS Analytics has tremendous data assets around technology, infrastructure, and contracts. The match with Definitive is about being a good shepherd of that data. By combining that information with all of the proprietary data that we have around affiliation, quality of care, and now our commercial claims database, we’re able to provide a complete picture for our clients that will give them a competitive edge.

Those clients include companies that are marketing into the healthcare provider market as well as providers themselves that are looking to expand their networks and understand where they can continue to grow their business through physician referral, analytics, and new affiliations. We offer a powerful solution to help advance the industry forward.

HIMSS is keeping the Adoption Model business and the consulting around that, right?

That’s correct. They’re going to continue to provide the EMRAM and the consulting around it. We will focus on the data business and the detailed provider information for both the vendor community and the provider community.

How have mergers, affiliations, and network agreements changed the demand for information as the market gets more complicated than just single hospitals and health systems?

“Complicated” is the operative word. As this industry continues to evolve and health systems become these extraordinarily complicated organizations that are big businesses in their own right, all the participants in this industry need to have access to data that can help them decipher what’s happening. Where are patients going for care? How do all these facilities interact with each other?

More and more, we’re helping our clients understand where there is patient overlap or leakage from one hospital to the next. Our clients are trying to solve that for providers, while the providers are trying to figure on their own how they can continue to protect their business and deal with new payment models. The complexity helps our business over time.

Will these larger corporate entities impose a corporate standard for systems such as EHRs and revenue cycle?

The speed at which mergers are taking place certainly makes that difficult from a technology standpoint. Health systems by and large have the strategy of moving to a corporate standard, but it takes time. Technologies that help these systems talk to each other become increasingly important.

The other important corporate standard is around decision-making for medical devices and pharmaceuticals. Health systems are trying to create standards across their entire organization. That’s good for healthcare. Standard therapies help patients overall and help understand new therapies that come to market. The move to control everything within their network continues, even though it is complex with the technology infrastructure.

Where will the three main inpatient EHR vendors look for opportunities now that the market is saturated?

They are doing some pretty interesting stuff, such as starting to work with insurance companies and different types of facilities such as treatment facilities. Epic is the largest EHR that works within the clinical trial space, which is an interesting way of growing for them. You’ve got all this rich patient data that needs to be collected in one fashion and Epic does well in that market. We’re rolling out a clinical trial product to address the needs of the pharmaceutical companies and medical device companies that we serve, but also the technology companies that want to get a piece of this robust market.

Even though they’re relatively saturated within the hospital and the health system market, these tangential areas are exciting growth areas for them. They open up a new opportunities in life sciences, insurance, and other areas.

Are drug and device manufacturers more interested in using the information that a typical hospital or practice would collect?

Absolutely. Data from EHRs has grown so much and become more standard over time. It’s a tremendous opportunity for improving the quality of care by analyzing that data, getting newly available information and at a larger scale across larger patient populations. There’s a massive interest in getting access to that data from the pharmaceutical side.

What kind of information could a mid-tier hospital software vendor get from you that would help them understand their potential market?

We have data on every single provider in the US — clinics, physician offices, imaging centers, hospitals, and IDNs — and the affiliation of all these facilities. It’s important to know whether they are owned by a health system or are standalone. We have the technology infrastructure data that allows understanding what each of those facilities are using. That data has become stronger through our acquisition of the HIMSS Analytics business. We also have information around the quality of care provided and the Medicare penalties or incentives that each of these facilities is achieving.

All of that is important for these organizations that want to elevate the conversation with their prospective clients. Rather than going in to talk about their product, they can go in and talk about what’s happening at the facility or the health system — the problems they’re seeing in their market and how that compares to other facilities they have. They can use that data to bring their product to life and show those prospective clients why their product can help meet the needs of that organization right now. Making your team smart and targeted to understand the business problems of the hospitals and facilities is an important value-add that we bring to our clients.

How do you see the company changing as it grows?

Our goal is to continue our product innovation. We have grown, mostly organically, over the last seven years at a rate of something like 175 to 200 percent per year. We continue to grow by selling more of what we have. We have a very good product of extremely high quality that covers the market really well.

We are also innovative in what we roll out to clients. In the last year, we’ve been more innovative than in the first six or seven years of our existence. We rolled out a commercial claims database that gives our clients access to data on about 210 million patient lives. We have over two billion claims. This allows our clients to understand diagnoses and procedure utilization rates by facility, provider, or physician. We’re rolling out a clinical trials database, and later this year, we’ll also be rolling out a database with specialty pharma data.

Our goal is to continue to stay on the forefront of new trends that are happening within the marketplace. Each time we do this, we open up a brand new market that we haven’t sold to before. Clinical trials opens up a multi-billion dollar industry for us. Commercial claims gives us access to all of these new markets we haven’t sold to before that need to understand what’s happening in the commercial market. All of this innovation helps us continue to grow.

Over time, we’ll continue to pull in more information, maybe from EHR systems as you mentioned, to help clients analyze that data. That’s potentially something down the road. We’ll start to get into more of health economics and outcomes research. That’s a great market for us. We see the runway as being extraordinarily long. We’re going to continue to grow at the pace that we’ve been used to over the last five to seven years.

Who are the prospects for the all-claims database and how can you correlate that information with your other databases to provide new insights?

Most of our client base is interested in the commercial claims data. Certainly some core markets are life sciences, providers, and tech firms. We take this data, where you can see this utilization by facility and physician, and make it extremely powerful by combining it with all of our proprietary data. Now you can start to do things like roll that data up at the IDN level. What does an IDN look like for knee replacements or other procedures or diagnoses? You can also combine it with things around the quality of care analytics that we provide.

Our clients take this claims data that’s valuable on its own, but we bring it to life and make it an actionable piece of information that they can use to define a new drug launch or develop their markets and create a go-to market strategy for whatever product they might have.

Do health systems use your information for competitive purposes?

We have lots of health systems as clients. They’re using our data to develop their networks, which of course is competitive to some extent. They are looking to develop new physician relationships based on referral patterns. They’re using our data to find merger and acquisition opportunities. We help analyze leakage outside of the system, Our clients are interested in understanding that. They can start to fill those gaps, because any time care is delivered outside of their system, it’s harder to provide the quality of care at the cost that they want to provide it.

How do you see the company’s future over the next five or 10 years?

It’s about continuing to expand our product offering. We have a big team of people that are being highly innovative in thinking through what the trends are within the industry. We can help our clients meet those trends head-on and stay in front of them. Access to our data and our analytics gives our clients a competitive edge. This market is moving fast. To be competitive, our clients need to stay ahead of the trends and we need to help them do that.

Over the next five to 10 years, we’re going to continue to evolve, add new product offerings, and potentially do more acquisitions as the market continues to expand so that we can provide the best data to our clients to meet their needs.

Do you have any final thoughts?

We’re a fast-growing company and there’s a lot of responsibility that goes along with that. We invest a tremendous amount from our company in terms of helping our employees grow as individuals and also to give back. We launched the Definitive Cares program about two years ago, where we have 100 percent of our employees doing a community service project throughout the year. They earn days off by being part of this program.

It’s an important part of our culture because healthcare is about helping people and servicing people. We want to bring that into the fabric of our culture. We help over 30 charities every year. We have a 100 percent volunteer rate within it. As a company, we gave over 3,000 individual service hours during the working day. All of that is important. My final thought is that continuing to give back is important to all corporations. We try to live that on our own.

HIStalk Interviews Sean Carroll, CEO, Arcadia

Sean Carroll is CEO of Arcadia of Burlington, MA.

Tell me about yourself and the company.

I am a 32-year veteran of healthcare IT over six companies, all focused on some aspect of healthcare data. Some of those companies were service-oriented businesses, some have been technology focused, and one or two have been a combination of both.

I’ve been on an explicit mission over my career to be part of tangible progress in the evolution of healthcare. I firmly believe that progress must be founded in healthcare data as at least as one of the major levers that has to be pulled. I’ve been at Arcadia for five and a half years. I’m glad to be here because Arcadia has the capabilities and positioning in the market to be an instrumental player in that necessary transformation of healthcare. We are seeing that with our customers.

The company is positioned as a population health management company, specializing in delivering population-level analytics in care management to enterprise-class customers. We serve enterprise provider organizations and nationally branded, recognized health plans. We also have a nice partnership business. Since we last talked in mid-2015, the company has experienced significant expansion and growth, elevating itself to 50 million patients and 50,000 providers in our platform. We have continued to maintain top rankings and positioning with all of the analysts who track this market since we emerged in the KLAS report in the end of 2016.

What changes have you seen since 2015 in population health management, value-based care, and the availability and harmonization of EHR data?

It has evolved a lot. One of the positive developments in the ultimate transformation of healthcare is that the commitment to value-based concepts has remained steadfast, even with all of the crosswinds that we all face every day politically and from other influential angles. That’s been a positive trend of staying in that direction.

The market has, without a doubt, matured in many ways in the last three to four years. Organizations that are pursuing technology or services that support value-based care transformation have probably been through one or two tries at implementing something. They have some battle scars and they’re smarter about what they want. Vendors who support them in this effort also have learned a lot about what it takes to be an excellent provider of technology or value-based care services to support these transformations. It’s hard work and the market has come to understand that.

A lot of companies and investors have jumped into population health management technology. What changes have you seen as companies have developed a good or bad performance track record?

The vendor landscape has changed the most in that time frame. Some organizations have fallen down or fallen out of the market. Investors and operators are learning that the economics of providing population health technology require substantial investment and substantial time for that business model to mature, all while simultaneously delivering a high-quality customer outcome. It takes a unique bond among investors, customers, and vendors to make it all work. We have seen that ourselves and with competitors who don’t have those elegant relationships and therefore have struggled or failed to be successful in the marketplace.

KLAS’s recent population health management report commends Arcadia and a couple of other vendors for being good at offering customers strategic guidance as well as technology. How does a health system move from the vague idea of becoming involved in population health management to then developing a strategy and looking at technology?

The organization first typically organizes, within themselves, the right core team to drive that agenda. It becomes a focused strategic element that is driven by a population health executive, title notwithstanding, who has a clear vision of what they’re trying to achieve.

Population health management has a number of entry points. Priorities can be set in a lot of ways. Sometimes we see an absence of priorities or clear priorities, but the organization has good leadership, good governance, and an understanding the foundational elements of successful population health implementation. That’s the starting recipe for how organizations come together. Where we come in on the strategic side is helping them, once they have or are implementing the right set of tools on the right data asset, determine how they might focus. These are very specific, on-the-ground efforts, given the outcomes we’re seeing through the data and the tools that we avail to them to explore that data. It’s a tactical strategy.

Are health systems and insurers interested in improving an individual’s long-term health beyond simply reducing their own short-term cost and risk?

That gets to the heart of what we believe is exemplary population health management. It starts with a clear economic mandate. We’ve shifted our business with all of our capabilities to focus on making our customers economically successful first, in terms of proper execution in their risk contracts, so that they have the opportunity to make other investments in population health management outside of that. We’ve learned in the past five or six years that there’s a lot of things to chase in population health for the good of population health, but sustained financial success is the bridge to sustained successful health management of a population.

Would an insurer approach population health management differently than a large health system?

I would say no at the highest level, but obviously they have different business mandates than providers. We’ve been able to foster the notion between health plans and provider organizations that a properly-positioned, highly-usable, high-quality data asset in the marketplace — where the population at large is visible in every sense of the word from a data perspective — serves all parties, both in their own strategic designs and in the broader design of what we all want for healthcare.

We talked last time about the number of provider organizations that either don’t have a data strategy or are knowingly or unknowingly using bad data to drive their decisions. Has that improved?

It definitely has improved. Everyone understands now that data is important. Not everyone has prioritized it at the top of the list of their value-based care strategy, which we would recommend be the case. We last talked that it was still, in many cases, a challenge to get some organizations to understand why clinical data was an enhancement for them in the context of a data asset. That really is no longer the case.

How do you position and differentiate the company?

A lot of the data work that we do demands a certain quality level that is informed by tenure. We have been working at data harmonization for longer than most organizations in the space, probably by an order of magnitude. Some of that shows up in KLAS reporting in terms of the types of enterprise customers who choose Arcadia. We hear a lot that that’s because of our experience. Outcomes, as in the tangible and referable results from the deployment of our technology over time — improvements in risk coding, reductions in total cost of care, dozens of other outcomes — we focus on seeing that our customers can not only deliver those for themselves, but are eager to talk to other customers about that. Referenceability is a crucial, crucial item for us.

From a market perspective, we’re the only vendor that serves both health plans and providers. That has continued for us since the beginning. That position in the market is important since we believe in this concept of density of market, where providers and health plans in given markets are working together to advance population health. We approach the market a little bit differently in that regard.

Do you have any final thoughts?

We are enthusiastic about where the market is. We feel fortunate to be in the category of leader in advancing progress in managing population health. We’re equally excited about the nature of the market, which has settled out with some really good companies trying to advance this important goal for healthcare.

As a company, we’re excited about our ability to deliver what we believe is the most important thing for the next phase of advancement in this marketplace, which is both speed to value and lasting value for customers. If companies like Arcadia can continue to deliver that to the pioneer organizations that are trying to advance healthcare by better population health management, then everyone will benefit. We’re excited to be in the top category of companies that are delivering against that.

HIStalk Interviews Eric Widen, CEO, HBI Solutions

Eric Widen is co-founder and CEO of HBI Solutions of Palo Alto, CA.

Tell me about yourself and the company.

I have a long background in healthcare, over 25 years now. I’ve worked and focused on solving problems in healthcare, typically using data. We started HBI Solutions with a more sophisticated bent on using data and data science techniques to solve problems in healthcare. That focus has been on predictive insights on patients and populations, so that population managers and even individuals can understand insights into their health that they wouldn’t know otherwise. We use data science methods to do that.

What are the implications of predicting the outcomes of patients who may not even know they have a problem, as you did in applying machine learning to EHR data to identify people likely to eventually have chronic kidney disease?

That’s the million-dollar question. The punch line is, what do you do once you know this information? Our clients are focused on low-hanging fruit from a risk standpoint. They’re working closely on readmission rates for acute settings.

We have two flavors of risk models. One is the acute setting, where our insights predict what could happen before and immediately after discharge. It’s typically an acute team or a post-discharge transition and care team that is focused on things like readmissions, and inside the hospital, sepsis and mortality.

The other models are population-based models. You want to predict what’s going to happen in the future to patients who are healthy at home. The chronic kidney disease, CKD, model that you referenced is one of those. But by and large, organizations are largely focused on utilization and cost as the starting risk models. They target patients that are at risk for ED visits, inpatient visits, or high costs, then proactively enroll them in care programs.

Our more savvy clients are starting to get into disease models. CKD is one of them. But more common use cases involve risk of mortality, which was the subject of a paper we published. We’ve had organizations looking at the risk of death for a patient in a future 12-month period and proactively teeing up discussions about end-of-life and palliative care. We have a heart clinic focusing on getting patients who are at elevated risk for a heart attack into the clinic more frequently than they would otherwise.

We said in our mid-2016 conversation that CMS’s excitement about preventing readmissions would probably end up being more tactical than strategic, not really changing outcomes as much as pushing costs around. What have we learned from trying to fix a problem with what might be a blunt instrument?

A key performance indicator that is put into place by regulatory agency that includes penalties and economic implications always tends to have unintended consequences. With a laser focus on something like readmission rates, you’re looking only at a 30-day window post-discharge. The health of those people continues forever after that.

It’s more appropriate to understand all the risk for an individual. Not only within that 30-day transition and care period, but also for the next year and multiple years after that. You get people into more of a comprehensive risk management program to bend the cost curve longitudinally over time and to take care of all the patient’s risks via care management, not just the 30-day readmission risk. Day 31 and after is as important more important than those 30-day windows.

CMS, Joint Commission, and others have come up with ideas that sound naturally good, but without having data behind them. How should those organizations use the same data science as your customers?

It’s not there yet, obviously. The other unintended consequence is the administrative burden that is bestowed upon clinicians and healthcare organizations to meet these quality markers. It’s a heavy burden and a heavy lift and it doesn’t always lead to high-quality care.

Our philosophy as a company is that we purposely didn’t start with regulatory measurement, or any of those, as a focus of the company. We do those things because organizations have to do them. But our philosophy is around two markers — are we reducing the cost to manage patients and are we getting patients healthier?

As the risk goes down for things like readmission rates, utilization of the ED, mortality, or for having a heart attack, patients are actually getting healthier and moving towards an improved outcome. We’ve had clients use our risk scores as a marker to graduate people from care programs. As their risk goes down, they’re getting healthier and they no longer need an aggressive care management approach. They are closer to self-managed care.

I don’t know how this will affect how a regulatory agency thinks about care, but we have progressive organizations thinking about care in that way. Keeping their eye on the ball on a couple of important markers that are really getting people healthier. As people get healthier, they use fewer resources over time. We’re starting to get into the measurement of the cost effectiveness of this approach.

In healthcare, however, spending money to improve someone’s health today might mean someone else gets the payoff decades letter when the patient has changed jobs or insurers.

There is that kick-the-can-down mentality a little bit in the commercial markets. However, Medicare is the largest payer and people consume the most of their costs and incur most of their diseases as they stay in those programs longer. With managed Medicare, Medicare Advantage, and Medicare HCO plans, you get more of a longitudinal outlook on patients. They stay in the same plan or program. We’re targeting those types of organizations, where those incentives are aligned, because it’s a better fit.

I have seen in the commercial space exactly what you’ve described, the “it’s not our problem” approach. They are more focused on short-term risks, more interested in what could happen in the next 6-12 months instead of the next 5-10 years for that patient.

What is your most impressive customer outcome?

It’s a mix. Organizations that have been with us the longest have shown good longitudinal outcomes in reducing ED visits and readmissions. That was their largest focus, and remains their focus, because they can put their arms around that and put in programs to bend those curves.

We can look to the future for graduating people from care programs, Then we can develop, for example, more mental health-based risks. Getting people to that point of self-help to lower their rate of suicide and opioid abuse. That’s the next wave for us, as the way people think about care becomes more sophisticated. We’re not there yet. That’s our future direction.

Beyond Medicare, the VA has the incentive to pay attention to long-term patient outcomes and to implement mental health programs. Have they expressed interest?

We’ve had several conversations with the VA through one of our partners, InterSystems, which has a long relationship with the VA. We have the ability to deploy into existing technologies as smart engines behind the scenes. We can work with any workflow platform. We plan to work with the VA in the future, but nothing is in place yet.

What data elements do you wish you could get but can’t?

Our approach is to give us whatever data you have and we’ll generate the best insights on your population or on you as an individual. As we look to the future, we’re starting to work with more partners. We’ll announce this as time goes on, but these partners have access to different types of datasets. We have worked with what’s generally available in the electronic medical record and in claims systems. We’ve added outside data sources that we can get from the federal government, like social determinants and things we can add in at the ZIP code and Census Tract level.

We’ve been pitching ourselves as a population health program, but as we look at the future and getting more towards the consumer, we’re starting to work with different datasets that would allow us to develop new diagnostic screening and/or risk tools. Developing tests that don’t exist today. We could, with a mass spectrometry partner, develop analysis of proteins, lipids, and metabolites within the blood itself. It’s new data that hasn’t been harnessed, other than in research settings at a very small population level of tens or hundreds of patients.

We’ve been analyzing millions of patients in a lot of our datasets. As we work with these new partners, they’re looking to secure large population samples in tandem with EHRs in the US, but more globally. Our metabolic makeup changes at a detailed level as we exercise or enter new nutrition programs. You can measure that on a day-to- day or week-to-week basis and pick up these signals. This is really new and interesting to us. It’s the same repeatable process around machine learning that we apply to other datasets. But getting into this, we can start developing new tests in the market.

An example is a newborn screening test, where researchers who work at HBI have, in the academic setting at least, identified for every pregnant woman their likelihood of pre-term. If you’re more likely to deliver pre-term, then you will enter a different care program. Any obstetrician or pregnant woman would want that test. We want to develop tens or hundreds of those types of tests.

Another example of high-throughput analysis of mass spectrometry is diabetics whose glucose and A1C markers are “normal.” We can find that 20, 30, or 40 percent of that “normal” population is actually at risk by measuring the proteins and the metabolites within the blood. This is a new direction for HBI. It doesn’t take away from our current direction, it’s just a new channel that we’re going after. It enhances population risk management, but individual risk markers will be a more meaningful focus for us.

How can we separate the real deal from the posers in the HIMSS19 exhibit hall, where every vendor will suddenly claim that their old products are now powered by machine learning, AI, and analytics?

We pride ourselves on being a no-BS company, rolling up our sleeves and working with clients to get them better technology to make the doctor’s job easier and to get patients healthier. We’ve always taken that as a focus. We can differentiate by giving you a list of physicians who are using our technology, pointing to research papers, and putting you in touch with care managers who are using our product daily to the health and outcomes of patients. A lot of vendors don’t have those three in place.

Do you have any final thoughts?

We have been focused on US problems and issues, which have their own government and regulatory components that drive how you think about entering the market here, But if you take a general view of how to use technology to get patients healthier at a lower cost, it’s relevant to US. There’s no shortage of studies on how upside-down the US is on outcomes and cost.

But it’s relevant across the globe as well. Other countries are getting richer and eating more poorly. People there with more disposable income want access to more types of healthcare. It’s a global problem as well. It’s important to think about how technology applies not only in the US, but globally. That’s our approach in developing solutions that are relevant to people.

HIStalk Interviews Kevin MacDonald, CEO, Kit Check

Kevin MacDonald is co-founder and CEO of Kit Check of Washington, DC.

Tell me about yourself and the company.

I’ve been doing RFID and helping various parts of all kinds of different supply chains for 20 years. I started with Sun Microsystems, did a consulting company, and then I started Kit Check in 2011. A friend of my wife was a pharmacist. She was on crash cart duty and having an awful time. I said, boy, there’s an awfully difficult and hard to manage supply chain for drugs inside the hospital, not to mention outside. I think we can make the pharmacist’s life better and more efficient while making the drug spend cheaper and the end result safer.

How are hospitals using Internet of Things and RFID?

You typically hear about RFID in hospitals for tracking things that you don’t want to throw away, like capital equipment and people. Real-time location systems are kind of expensive. We focus on things that you actually do throw away, consumables such as, in this case, drugs. There’s a great ROI there. We are approaching 500 hospitals now and growing very quickly. We are thrilled that we’re now tracking more than one new medication every second, but there’s still a lot of room to grow.

The potential benefit in labor savings and medication tray dispensing accuracy is obvious, but how would a hospital pharmacy use your system to manage a drug recall or manufacturer shortage?

Imagine you have 150 carts across the hospital. Something is recalled. You’re going to send a tiger team of pharmacists around, taking hours or probably days for many people to open up and check each individual cart. Our system knows every single vial and every single place. We know exactly where to go to address recalls, where you do and don’t need to go. That multi-day process goes down to a matter of minutes, unless of course the recalled drug is absolutely everywhere, in which case you need to go to all the carts anyway.

As we’ve expanded to so many hospitals, we have a system where if two hospitals enter a recall, we scan everyone else’s inventory. We say, hey, you have a drug that was identified as recalled by other hospitals. We’re often ahead of both FDA and RASMAS in recalls.

Do you see other potential for network-effect type usage beyond a single hospital?

There are things around benchmarking. Everyone is constantly trying to figure out, what do I put in a crash cart? What do I put on the anesthesia floor? It’s typically a discussion or a debate rather than a fact-based situation. We can bring data about both what’s in your hospital as well as what others are doing. That makes it a clearer debate.

With controlled substances, the more data we have in the system across hospitals, the more we can learn additional patterns of how people divert medications. We can then make everyone smarter along the way. It’s incredible how many ways people find to divert controlled medications. Having more and more hospitals on the system allows them to get smarter and smarter every day.

How does your Bluesight for Controlled Substances improve on software provided by drug dispensing cabinet vendors?

The biggest difference is that it takes in multiple data sources and then layers on workflow to do 100 percent closed-loop auditing so that it is comprehensive. It also brings in data from the EHR and other systems and then layers machine learning and AI on top.

Dispensing cabinet reports can tell you that a nurse dispenses twice as much fentanyl as another nurse, but there might be a good reason for that. Perhaps they’re doing a cardiac surgery case in the OR. We can look at all patterns, including locations, waste buddies, and time between events, whether it’s dispense-and-admin or dispense-and-return. We understand the situations that are riskier.

At the core, we’re doing three things – identifying potential risks, adding workflow to make it actionable, and making it comprehensive by enhancing dispensing cabinet information with data from EHRs and other sources, such as time and attendance systems.

At least two nurses have confessed to killing dozens of inpatients using ADC-dispensed drugs, yet weren’t caught for years even though the correlation to specific drug withdrawals or the number of codes called on their work shifts seemed obvious after the fact. Is that business case for your system even though it’s hopefully a rare event?

It’s not easy to prevent, for sure. It is prevalent. Studies have shown that as many as 8 percent — one in 12 nurses, anesthesia providers, and pharmacists — will end up diverting controlled substances. If you take a trip to the hospital and touch a lot of different folks, you have a pretty high probability that some of them are diverting.

That goes along a spectrum. Typically, someone starts out slowly. They were playing soccer or something on the weekend and got injured, then decided to do a little pain relief. It slowly builds and gets out of control. Any given hospital at any given time almost certainly has diverters. If they aren’t finding them — which, by the way, most aren’t — there’s risk to patients.

Software vendors are claiming that their old products are suddenly using machine learning and AI when they’re actually just running queries. Is your system actually independently learning from the data it sees?

Over time, it’s learning individual patterns and behaviors as well as group patterns and behaviors. At the macro level, we look at several trends across all hospitals. We add in, for example, a waste buddy report, pain score report, or something like that across hospitals. A 100-bed community hospital is very different from an 800-bed academic center. Even between academic medical centers, the practice habits are going to be different.

We learn the practice habits at that facility and for groups of people. If you are a NICU nurse, your patterns will be different from an anesthesiologist or investigational radiologist. We learn over time what is a normal pattern and what is an abnormal pattern, We’re also looking at individuals to see if their behavior is changing over time and learning what is normal for them.

Unlike some other things where it’s just, “Let’s take a bunch of data and run some reports,” there actually machine learning and AI happening here.

That would require the system to also know when someone was positively identified as a diverter so it would know it predicted correctly. Is that information provided to the system?

We call it an investigative workflow. We identify the folks who are more risky. We’ll never say that someone is absolutely diverting, because there may be something strange that happened that caused them to spike on whatever the set of tools are.

Once the hospital starts an investigation, we give them the capability to drill in transaction by transaction. They can start conversations with management. They can then go further in the investigation workflow and escalate up to the time where someone is engaged with HR, rehab, or potentially criminal proceedings. But hospitals usually try to help their providers recover instead of instituting criminal proceedings.

We end up learning when all of these things happen. We also see patterns that we’ve seen elsewhere that we might highlight more, or other things that we want to take a look at and then apply to the rest of the hospitals in the dataset.

Your company has gotten pretty big, but it sits between EHR vendors and tray and drug dispensing technology vendors, both of which provide information your product needs even though they may have similar offerings. Are you concerned that being successful might cause those big companies to take action in developing a competing product or cutting off access to their information?

Our advantage is that we are big enough to have a good-sized engineering team, but we’re small enough to be nimble. We release new code and new functions every two weeks. Those large vendors are often on an annual cycle. It just takes forever. You need constantly update the patterns and the data feeds you’re looking at.

We think we’re well positioned, and in terms of the data we need, it’s fairly standard. We can do an HL7 interface, but most folks end up pulling standard reports out of both their EHR and their dispensing cabinets that they end up using for other purposes. I guess those companies could try to do something anti-competitive, but for the most part, we’re just using what’s already out there.

One of the most anti-competitive actions they could take would be simply to whip out their large checkbook and buy you out.

We’ve got a lot of room to develop. Our core is helping hospitals do those three things that we talked about — saving money on drug spend, being safer and more compliant, and being more efficient. Those all come down to having visibility at the item level. We started in the procedural spaces, where the hospitals were blind. Even if they had a dispensing cabinet, typically the dispensing cabinet counts were way off. We got almost perfect visibility in a place where they were blind.

We now have added the nursing floors and the other areas by our learning controlled substances. Over time, we’re going add more and more tools that help the hospital automate things, and again, do those three things. We are venture backed and we’re going to grow and become a bigger company, but we’ve got a lot of growing to do in the mean time.

How has the company changed in moving from a business that you personally bootstrapped, sweating those first sales because hospitals take forever to make decisions, to become a significant, venture-funded player?

It ha created a lot of opportunity. My co-founder and I were cold-calling. Neither of us had worked with hospitals. Honestly, knowing now how bad the hospital sales cycle is, I’m not sure that we would have started the business.

Having scale really helps. With the venture rounds, our investors have been super supportive. They believe in what we’re doing.

We’ve been able to build a decent-sized engineering team. Compared to the dispensing cabinet vendors of the world, I think the amount of engineering that we’re putting on software is bigger than some of the publicly traded guys. We can hire amazing people because we’re doing important work. It’s easy for people to get behind that important work as we grow. That’s the most interesting thing about scale.

We were at the American Society of Health-System Pharmacists Midyear conference recently. It was really cool to see all the customers out there. We’re not, as one director of pharmacy called us years ago, two nerds in a metal box any more. We’ve got scale and products and we’re solving important issues for the pharmacy. We’ve proven that. We do a good job at it.

Do you have any final thoughts?

We’re super excited to be helping our hospital partners, and going forward, not even just hospital partners. We’re working on getting drugs already tagged to the hospital and being able to have full traceability in the supply chain to allow those hospitals, again, to be safer, be more efficient, and lower their drug spend.

HIStalk Interviews Peter Butler, CEO, Hayes Management Consulting

Peter Butler is president and CEO of Hayes Management Consulting of Wellesley, MA.

Tell me about yourself and the company.

I’ve been at Hayes for 25 years. We are a technology-enabled company leveraging our MDaudit software platform to drive billing and audit compliance productivity as well as revenue integrity solutions across healthcare organizations.

Is it hard to retool a consulting firm into a software vendor?

It’s challenging. After a long corporate career in consulting, you develop a name for yourself in that area. We got our start with IT consulting, then over a period of time, moved into revenue cycle consulting and EHR implementations and so forth. Our MDaudit platform took a greater foothold in the industry and we were experiencing quite a lot of trust with it.

We saw this, years ago, as the future direction of the company. We foresaw health IT consulting needs diminishing and becoming commoditized. We wanted to leverage our strength. That’s when the software piece came in.

It was a difficult journey trying to change the mindset of a 25-year-old company and people who have a lot of longevity in it, asking them to think differently, more like a software company. It came with a lot of challenges.

Are you happy that you made that decision early when you see other consulting firms just now starting to react to market changes?

Very happy. When we were going through that transition, the hardest part was that it wasn’t happening fast enough. I look back in the rear-view mirror and say, OK, we did it. We got there. This is good. Where do we go from here? It’s important for us to stay relevant in the industry and in our client organizations.

We’ve turned the corner. We are looking forward to building ourselves as a software company and continuing to make a difference in healthcare.

What are the top issues in billing compliance?

Years ago, the top issue was how a healthcare organization with 2,000 providers could audit all of them annually. Then they acquire two more medical groups of a couple of hundred providers. How do they get through those audits with limited resources? Their organizations weren’t giving them the staff since they were really seen just a cost center.

Now the trend is, I have limited resources, so let me take a step back and look at all of the billing compliance risk areas to my organization. Bubble those to the surface so that I can take my limited resources and go tackle those challenges. Are they really risk areas that I should be concerned about, or are we a billing outlier for good reason because we are multi-specialty and we specialize in this type of service? In the old days, they were looking for fraud and abuse inside their organizations.

Now it’s taking a different turn. Where can I sharpen my attention to the revenue cycle? What am I actually providing for service, but not billing for? Compliance officers stay in the mindset of looking for areas where they can ensure that their organizations are billing appropriately, not over-billing Medicare things and like that. But they’re partnering with revenue integrity leaders inside their organization who are looking at the same data. What are we leaving on the table? We’ve delivered these services. There’s more pressure on reimbursement. We want to make sure we’re getting paid for everything we’ve done.

Is anybody doing a lot of billing compliance work as due diligence before provider acquisitions or mergers?

They are, but they should be doing more. I’ve had conversations with compliance officers who said, I just got a message from the CEO that we’ve signed our letter of intent. We’re moving forward with buying this practice or hospital. They aren’t paying attention to making sure that, as part of the due diligence process, they are billing and coding appropriately. Let’s understand the risks of acquiring this organization. It’s almost been an afterthought from senior leadership that the compliance professionals find themselves in post-transaction.

Is the focus different when a private equity firm is the buyer, such as the trend of acquiring dermatology practices?

We’ve had some of those PE-backed companies call us and say, we’re about to make an offer for this dermatology practice. Before we finalize it, can you do some diligence around their revenue cycle and their billing practices? Make sure that they are billing and coding appropriately and that what they are telling us and what we’re reading in the reports is actually what’s happening.

Those are mini-assessments. They don’t take a lot of time, but they give the buyer an opportunity to understand where the risks and opportunities are. Once they finalize the deal, if they go forward, where can they find revenue opportunity and operational efficiency? There’s definitely a lot of that from the financially-minded buyers.

What trends are you seeing that aren’t getting much attention?

A lot of revenue cycle leaders in years past ran their organizations based on metrics. They would tell their staff, you need to make X number of calls or you need to touch X number of claims. A trend I’m seeing that will pay dividends later is that instead of looking at volume-based metrics or metrics for the sake of metrics inside those revenue cycle follow-up departments or patient access departments, ask that if you touched a claim, what did you do with it? Did you make changes to it that positively affected the organization? Were you able to identify root cause and go back and make changes that actually stuck so that we’re not seeing these problems over and over?

Some of our clients are assigning audit-minded people to look at the goals and responsibilities of those who support the day-to-day operations. Looking at whether their daily tasks drive positive change, the quality outcome in the operation. They are using spreadsheets to document who they’re working with, the types of audit completed, the follow-up, and the result.

It can become an arduous task, but the concept is, are you driving better quality outcomes in your role, or are you just saying you made your 50 calls or worked your 10 work queues? What was the result of that? That’s an important trend and overdue in healthcare.

Hopefully we can instill some best practices in the industry so that we have less need for those auditors. You’ve done your training and you’ve built some great training programs to educate the people who are touching every aspect of the business operation.

Do you have any final thoughts?

Some interesting things are happening that we’ll see more of as quality reimbursement plays a bigger role in healthcare. CMS recently proposed some E&M simplification rules with the concept that it will save money and provider coding time. They’ll save 50 hours a year or something like that, taking away all of the detail-level E&M coding and documentation you have to do. CMS is also looking for ways to save money for the taxpayers and the government, so it has to be viewed through that lens as well.

It will come at some point, probably not in January, but it will come with challenges that the healthcare industry needs to walk through. If you’re billing Medicare, you’ve got Blue Cross Blue Shield as secondary, and you’re doing simplified billing for Medicare, what do you do with that claim? It gets passed down to a secondary payer. There are other issues around RVUs and how you reimburse your doctors that will be impacted by changes like this from CMS. We have a lot of work to do as we think about simplifying the billing process in the industry. It won’t come without challenges.

HIStalk Interviews Kurt Garbe, CEO, IMAT Solutions

Kurt Garbe is CEO of IMAT Solutions of Orem, UT.

Tell me about yourself and the company.

IMAT Solutions solves the core data problems of healthcare companies. We focus on how to improve data quality, data currency, the amount of data, and the type of data that companies can look at.

How do you position the company among competitors?

Many companies look at different parts of data — analysis, cleanup, or integration. We take a more comprehensive approach. This is a data platform. What are the requirements for the different types of data you’re trying to bring in, the comprehensive data? How do you look at cleaning up the data that’s coming in? How do you look at the currency? How do you make sure you can quickly access that data in a comprehensive way? We look at all of those components, not just some individual pieces and parts.

How would you assess healthcare in terms of your C3 framework of data that is clean, comprehensive, and current?

Healthcare is still, unfortunately, at the early stage. We know this from talking to our customers. It’s across the board. Different companies have different strengths and focus on different things, but we haven’t found a lot of evidence that people have taken the full picture and made a lot of progress.

Are healthcare organizations making decisions using data that is either bad or incomplete?

Absolutely. The core question is, what data are we even talking about? The data related to healthcare and the health of an individual includes a lot of free-text data, unstructured data from lab reports, notes, and so forth. When we talk to people through surveys and discussions, 80 percent aren’t looking at that data yet. They don’t apply natural language processing to figure out what insights they could get from that data.

It’s the old story about the elephant. We look at data as this big elephant. Some people look at data as just the foot or the trunk. They’re only looking at the pieces and parts. They don’t usually say their data is good — they admit it’s a challenge, something they’re looking at, or the subject of some new initiatives. We don’t find a lot of complacency and satisfaction.

It gets more complicated where a health system has several groups. Each says they have clean data, and they probably do to a great extent, but the data is not coordinated. How they describe their data and how this other group describes their data are not consistent. It’s therefore not particularly useful in having a real impact.

What due diligence is required before accepting a new source of data to understand its semantics rather than just finding matching columns that can be joined to create a bigger database?

I wish we identified some rules of the road out there. This is a major effort and a major problem. Like everyone in data and healthcare, they’re doing the best they can. Often they’re just prioritizing. They are saying, we can’t absorb all the data, but can you give us the following type of data so we can work on that first? Let’s cut the problem into small pieces.

That’s a practical approach that works, but it takes a long time. They are often disappointed with the impact of those efforts. You get the greatest impact when you’re using the largest amount of data to make decisions.

Will artificial intelligence and machine learning help solve the problem?

We’re in an unfortunate race. People talk a lot about AI and machine learning. But with these systems, as much as they’re making great progress in AI and machine learning, the inputs — unstructured and free-form data — are still weak. An AI engine or machine learning algorithm can’t necessarily turn it into something meaningful and useful.

Years ago, everyone was talking about predictive analytics. We have these great models, but the source data isn’t very good. You’re trying to do more analytics and use more of these advanced tools on poor data to get to that answer faster, as opposed to getting a better answer. People still have to spend a lot of effort to to turn unstructured data into something useful and meaningful that a predictive analytics engine, AI algorithm, or machine learning can do something with.

The challenge, and it’s a big one, is that the unstructured data multiplies the amount of data you have by a factor of five or 10. It’s 10 times more than you used to have, so how do you get meaningful results from it in a meaningful time frame? If it takes a week to process through all that data every time you run a report, create a model, or do some analytics, you’re not going to do it often. That’s why we talk about the currency, meaning how quickly you can get insight out of all of this data that you have.

That’s why we talk about the C3. It’s not just the fact that you have comprehensive data. You’ve got all of your data in an unstructured form, and through an NLP process or even manually, you’ve cleaned it up. It’s consistent, it works well. But now, how do you get results out of that in some meaningful time frame, where you can run reports, look at the reports, and say what works, what doesn’t work, or look at these fields instead? You’re now interacting with the data. That’s where this third C of currency comes in. That’s the only way you get high impact from whatever tools you have, whether it is predictive analytics, AI algorithms, or machine learning.

What lessons did you learn from connecting the aggregated datasets of two HIEs together after Hurricane Florence and validating that the result was accurate at a patient level?

The historical approach to interoperability or interconnecting data is to tell Company A, “Here is how we want you to give us output.” That’s historically a huge problem. Company A doesn’t have the time or they don’t see the value of doing that. Our approach is, just give us what you have. We won’t ask you to change your formats, your fields, or anything else. You give us what you have, this other organization does the same, and we’ll re-index that data and provide one comprehensive view.

The major lesson that we’ve learned in integrating new clinics and new hospital groups into these data pools is that we have to lower the bar of what they have to do. We’re not asking them to change their format, because those IT discussions are often where interoperability gets bogged down, where you ask people to change what they do. We don’t do that. Just provide us what you have and we will make it work for you.

How do you see the company and the general areas of data interchange, quality, and interoperability changing in the next five years?

Our aspiration, and the hope that we have for healthcare, is that tools such as AI, machine learning, and predictive analytics can help deliver real results now. We need to raise a bar on the baseline of getting comprehensive data, making it current so it can be analyzed in real time, and making sure it’s clean, consistent, and makes sense.

If we can get to that baseline, those other tools will get you what you want in healthcare — bending the cost curve, improving outcomes. Without that, we’re still in some ways guessing. If we can address the core data issues, those tools, as well as others that we can’t envision today, can help us make decisions on what it actually happening instead of guessing, which is what’s happening now in healthcare.

Do you have any final thoughts?

The topic of improving healthcare through data is not new. It has been envisioned, talked about, and hoped for for 20-plus years, if not longer. What is exciting now is that the technology, the ability to actually get there, has caught up to that vision. We look forward to helping make this vision come true.

HIStalk Interviews Rachel Marano, Managing Partner, Pivot Point Consulting

Rachel Marano is managing partner and co-founder of Pivot Point Consulting of Brentwood, TN.

Tell me about yourself and the company.

I’ve spent my entire career in healthcare IT, almost 18 years. I’m a computer science graduate. I started my first job at Cerner, where I learned the healthcare IT industry through the Cerner consulting concept. I eventually moved into the hospital side, going to work for Advocate Health Care to get off the road. I did a good bit of implementation and then worked my way into the Epic space and became a certified consultant for a variety of consulting companies. I did everything from build to project management at the project director level.

I launched Pivot Point Consulting in April 2011 with the intent of continuing in the healthcare IT industry, but as a consulting group and a vendor. I’ve seen multiple angles of the industry — software development, the hospital side, the consulting side, and now as an entrepreneur in the healthcare IT space.

What are the most important things you learned from working with Cerner and Epic and their products?

Their products are achieving the same goal, but have different ways of getting there. Both have strong implementation methodologies. Obviously their philosophies and corporate cultures are different. Cerner’s support model is different from Epic’s. Pivot Point Consulting serves both markets.

I’ve worked on both sides and have seen the advantages of both systems, the integration, and how they play in the industry. My roots are Cerner and I spent a good part of my career in Epic, so I think they are equally important in this industry. They create tremendous value for organizations. Many of our consultants have found themselves in both worlds over the years.

Cerner has made a lot of advances in their interoperability and in the international market, which has given them many additional clients. Epic continues to grow domestically and internationally. Epic has a unique way of managing the implementations — giving feedback, doing progress reporting, and ensuring success in install, implementation, and outcomes — which is different from how Cerner manages its clients. They are different animals, with both achieving the same end goal but with different paths to get there. We’ve seen tremendous success with our clients on both products.

How has hospital and health system consolidation affected the consulting business?

It’s certainly a different landscape when there is a lot of merger and acquisition activity. But by definition, that creates opportunity for migration, implementation, and optimization in consolidating older systems to one standard system. It has created a lot of strategy, advisory, and assessment-level work for us and in the entire industry. We’ve done quite a bit of M&A work in the last few years in helping with pre-planning, organizational IT strategic planning, and infrastructure planning for M&A.

We’re doing a large M&A strategy session right now with an organization in downstate Illinois. They didn’t know how to approach the amount of M&A they will be going after in the next 10 years and how that would affect them operationally, strategically, and financially. We put together roadmaps.

Consolidation has, from a consulting perspective, allowed us to look at the industry differently and to see the future state of where these systems will be. Many of them will be unified, integrated, and on similar platforms instead of best-of-breed. We’re going to see a lot more organizations on one platform where they can transfer data more easily.

Are large health systems in less of a hurry than before to rip and replace the systems of the hospitals they acquire in favor of the corporate standard?

One of our larger clients spent probably $200 million on Epic implementation over the years. They were bought by a much larger organization. Things are integrated between the two systems other than the Epic instances. The large organization is maintaining its existing Epic instance and the smaller organization will maintain its Epic instance. They’re both on Epic, but they are running independently by design.

The sheer cost of starting again, redefining workflow, and standardizing all these things between the two systems almost makes the juice not worth the squeeze after these organizations have spent so much money. Things are working, they’re getting the reporting that they need, they’re compliant, and their workflows and operations are efficient with those instances. It makes great sense for some organizations, less for others. Ultimately cost, resourcing, staffing, and other competing projects all come into play into that decision-making. But for some organizations, once they sign on the M&A dotted line, they’re moving forward and starting with the migration.

What projects are floating to the top of health system lists?

We’re seeing a lot of patient engagement, population health, privacy and security, optimization. A lot of managed services, outsourcing the support of these systems. More organizations are shifting energy away from EHR to ERP. The concentration is now that we have the data, what do we do with it? How are we using those measurements to improve performance, clinical outcomes, return on investment, and cash flow? It’s a much more advanced space.

Almost all of our clients are focused heavily on patient engagement initiatives in one way or another. How patients are interacting with their patient portals and what their experience is like from a technology perspective. Systems are in place, we’re live, software is working. Operations, workflow, and clinical and revenue cycle are functional. Where do we go from here in these Phase 2, 3, and 4 post-live scenarios?

Do health systems know what they want to do with population health and patient engagement or are they looking for direction?

Both. More-tenured organizations that have been on these EHR platforms and have software, analytics platforms, or tools are much further ahead in deciding what their initiative looks like or what it should mean. We have small organizations that haven’t even said the word. They’re looking for our guidance and our advisory around the right moves. What tools should we be working with? What vendors are good in this space? Should we be bringing Healthy Planet live? Should we be doing some type of integration?

Most of our large organizations are already underway and have someone leading the charge with population health in some regard. Some of our smaller organizations that might be a little bit further behind are looking for direction and directive. Some don’t know how to approach it, it’s lower on their list, and they’re still trying  to get their technology in order.

What do CIOs tell you is the hardest part of their job?

I haven’t heard as much about CIO turnover. You’ll see it with M&A, but jobs are also evolving into other areas. Some of our CIOs are more focused on innovation and driving revenue into the IT department where before it was more about creating a specific technology infrastructure.

Their challenges continue to be resourcing. I hear this consistently. How do we continue with additional future-state projects with the existing staff? How do we leverage organizations and potentially managed services or outsourced solutions to maximize our organizational resourcing?

Definitely innovation. We have CIOs who are focused on developing programs internally in their IT departments to drive revenue, to create revenue-generating entities within their organization that can align potentially with their IT shop. Potentially consolidating efforts with other local hospitals, leveraging other IT departments and their resources. We’ve seen a lot of unusual approaches to the post-EHR implementation world in CIO roles and evolving how they play in their organizations.

What are the issues most commonly involved when a health system calls you wanting to replace an incumbent consulting firm?

Typically we find that organizations are unhappy with the relationship, the level of consultant talent, or potentially the level of experience and ability. A lot of times, we’re called on because they’re unhappy with the level of service.

But we also find that organizations are looking for a firm that can do more than just one thing and can cast a wider net of service offerings. The group understands their culture, nuances, and their uniqueness and are able to go in other directions, whether it be at an advisory level, a managerial level, legacy, potentially on revenue cycle or clinical, training, and managed services. We’ve seen a good bit of that and we’ve seen organizations that are looking for companies at a certain KLAS level, where they’ve had vendors that have fluctuated in that KLAS standing. Organizations consistently say they’re looking for vendors within the top 10 in their category and that’s who they stick with.

Our focus is relationships, trusted advisory, strategic connections with our clients, and offering value. Being able to identify a challenge and provide a solution. We can do that at more of a strategic level, but also with staffing. We’re trying to approach it differently. We definitely do staffing, but we’ve always been a firm that has been consultant led and consultant driven. We have a different vision on how we work with clients and how we engage with them.

What are the biggest opportunities and threats for health systems, CIOs, and companies in the next 3-5 years?

Merger and acquisitions. We’re going to see in the next 10 years more and more organizations being consolidated, with fewer and fewer independent organizations. The challenges come with combining facilities, the cost of doing that, and technology integration. That will drive the future of the healthcare market. The continued advancement in the technology itself will also change how we are leveraging data.

Do you have any final thoughts?

Our organization is evolving and certainly has changed over the years. When Pivot Point started, we were focused pretty heavily on Epic and Cerner implementation. At that time, that was where the industry was, and that was the main focus of most organizations. We have changed with the times and evolved with the industry and continue to meet the needs of our clients.

We have cast a wider net into some of these divisions, departments, and areas where we see challenge and opportunity. A lot of that is around that managed services space and assisting clients with post-live initiatives. We’re going to continue to see more organizations putting energies in and around that as well as the strategic and more challenged areas around privacy and security, population health, mobility, and even compliance and infrastructure and technology.

HIStalk Interviews Rizwan Koita, CEO, CitiusTech

Rizwan Koita is CEO of CitiusTech of Princeton, NJ.

Tell me about yourself and the company.

I’m the founder and chief executive officer of CitiusTech. We founded the company in 2005. This is my second company — I started a tech support company. Before that, I spent about five years with McKinsey & Company.

When you and I spoke last in 2015, CitiusTech was about 1,600 or 1,700 people strong. We are now at 3,200 people. It’s been a fairly strong growth year this past year and over the last few years. We do a whole bunch of stuff in healthcare technology for our customers across what we call the Clinical Value Chain.

What is driving the company’s strong growth?

From the revenue perspective, we are now part of the Healthcare Informatics Top 100. Our revenue was $127 million last year and are on track for close to $150 million this year. We also made a strategic investment in a company called FluidEdge Consulting, which is at about $25 to $30 million. We are hoping that, on a consolidated basis, we will end this year with revenue of about $175 million. As you can see, that’s a very significant jump from where we were last year.

The growth of the company is essentially coming in a couple of areas. We do a lot of work with payer organizations in the US market. We do a lot of work with provider organizations. Both of those markets have accepted CitiusTech solutions and our services very nicely. We also work with some of the medical software and technology companies and support their growth. That business is actually doing quite well. It’s a fairly homogeneous growth across our offering with providers and tech companies as well as with payer organizations. To a smaller extent, we work with pharma organizations as well.

There is a tremendous shift toward data management, a tremendous shift toward analytics, and now a significant shift toward data science and machine learning. We at CitiusTech have a significant amount of expertise in these areas. We’ve been able to do value-added work for our customers.

How will artificial intelligence and machine learning affect healthcare in the next five to 10 years?

I’m going to talk about history a little bit. Ten years back, the emphasis was on deploying what I would call foundational applications, such EMRs, health information exchanges, and connectivity software. A lot of big problems in data integration still remain and are getting solved. Steadily the focus of the industry has moved towards, what do we do with all the patient data, clinical data, financial data, and operational data that is getting generated? What’s the best way to manage that data? That could be on-premise, cloud, or a more traditional enterprise data warehouse versus big data solutions.

After the data management problem starts to get solved, the next logical question is, how do we start to use more analytics? Increasingly there is a lot of focus on what I would call the standard analytics, like regulatory reporting and and Level 1 analytics. But as the industry is maturing, we see a tremendous focus towards a slightly more advanced analytics. How do you take this massive amount of data that is now getting captured — EMR, lab, pharmacy, or claims — and put it together to be able to solve more complex problems? These are often not possible to solve using traditional analytics, But some large healthcare entities are using machine learning and AI tools to use that information to drive their problem solving.

If you look at the market, there are a lot of smaller proofs of concept and very interesting pilots going on. But the number of real-life deployed applications at scale is still small. You have lots of tools and utilities, but a small number are actually being used for inpatient care at scale. We are trying to help our customers solve that problem.

There is a dichotomy between what’s happening in pilots, research, or academic settings but little of it in production. In the next five to 10 years, we are going to see a tremendous number of successful models getting deployed in the real world for improving patient care, improving efficiency, and reducing cost, all of which are critical for healthcare.

Will use of AI and machine learning create a competitive advantage for health systems that deploy them more quickly or skillfully?

There will be a clear stratification of the types of organizations that can use machine learning and AI. At a simple level, if you take the provider market and hospital systems, a very large entity — Mayo Clinic, Cleveland Clinic, New York Presbyterian, Baylor Scott & White, and other large health systems — will be able to gather that information, and for research purposes or otherwise, build and create their own models.

The bulk of the healthcare ecosystem will largely be dependent on the vendor community to facilitate the use of such advanced tools. If I had to fast-forward five to 10 years, I would say that a lot of the deployment of these tools will be driven by the vendor community — EMR vendors, medical imaging vendors, lab services companies, or some of the other guys who have the financial, intellectual, and technical horsepower. They can aggregate large data sets, build models, and then test those models and get them through the FDA approval process and other barriers that are required before deploying these models in the real world. I see a greater likelihood of that happening. Some of the very large health systems also have a strong R&D inclination and have the ability to drive innovation, but that would be much harder for mid-tier and small hospital systems.

Thousands of models are being created today in healthcare using machine learning and AI. These models can be created in hospital research centers, academic institutions, or by five guys in a garage who have deep clinical insight. If you look at thousands of these models and then look on the production side, you find that the number of real-life applications in production is low.

The reason for that is that customers are getting bombarded by a lot of models — created internally or externally — but they don’t necessarily have the skills required for model validation. Imagine that I’m a large medical imaging company. Tons of folks are coming to me and saying they have great algorithms for medical imaging. I as a medical imaging company must have the horsepower to be able to put together a team that can independently take clinical data, run it through the models, validate the efficacy of the models, and fine-tune the models before I can validate whether the model is effective or not. Model validation is a huge pain area for the industry.

The second area is model operationalization. If you have a validated model, the task of integrating it with the clinical workflow is reasonably complex. Say, for example, that I have a model in medical imaging. Knowing that it’s a validated model, I still must be able to incorporate that model into the workflow of a radiologist. If it’s a colon cancer detection algorithm, then the characteristics of the colon cancer patient’s image needs to then fire up this AI or machine learning algorithm. The algorithm should be able to give back a response that is clearly visible to that radiologist or specialist who is looking at the colon cancer image. The radiologist should be able to either accept or reject the proposition or the findings of the machine, the AI algorithm. Once they accept it, that information should get fed back into the algorithm to incrementally optimize and enhance the algorithm. The result should be presented back as part of the report or to the patient or what have you.

It requires a certain degree of engineering effort to incorporate the model into the clinical workflow in addition to meeting the data science capability. To operationalize the model, you need a bundle of different skill sets — data sciences, product development, QA and validations, and perhaps FDA certification.

We find that technology companies and hospital systems that are trying to operationalize their data science models often don’t have that blend of capabilities that is required for them to truly operationalize the model. We end up with a scenario in which there are a lot of pilot models, the number of models that are validated are fewer, and the number of models that are operationalized is really, really small. Obviously these things will change in the next five years, so we’re at a very exciting juncture, but it will require a serious level of thought on the part of the stakeholders to be able to actually achieve the validation operationalization, which is one of CitiusTech’s core value-add to our customers.

Do you have any final thoughts?

Our company is on an interesting trajectory where are helping our customers drive innovation in healthcare. We are also seeing tremendous growth from a business perspective. I’m really excited about the kind of work that we are doing for the segments that I described. We are setting up a very strong advisory board that we will announce in the next two or three weeks. We’re doing other things to drive the growth of the company both organically and inorganically, actively engaging with other companies that may have complementary skills and solutions to ours. I’m really excited about the growth part of the company and looking forward to the next five years.