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HIStalk Interviews Dean Sittig, PhD, Professor, UTHealth

January 30, 2014 Interviews 1 Comment

Dean F. Sittig, PhD is professor of biomedical informatics at The University of Texas Health Science Center at Houston and a co-author of the SAFER (Safety Assurance Factors for EHR Resilience) Guides that were developed for the Office of the National Coordinator.

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Describe the SAFER Guides and their purpose.

Following the IOM report in 2012 on patient safety and health IT, ONC promised that they would create some guidance to help organizations improve the safety and utility of their EHRs. The SAFER Guides were their attempt to do that. They contracted with us to develop them.


What do the Guides contain and  how would you recommend that a hospital or health system use them?

There are some complex organizational structures, but mostly the Guides have about 10 to 25 recommended practices that are very general. Something like, “You need to back up your mission-critical hardware and software.” The Guides also have examples to help people understand what that means, so for a backup, that ought to be an encrypted, offsite backup taken on a daily basis.

There is also a rationale to help people understand why they would do that particular practice. There are a lot of references to link people to different aspects of the scientific literature from where those ideas came from. If the items on the list were either from the HIPAA guidelines or the Meaningful Use guidelines, we link those to give people a renewed emphasis on why they need to do certain aspects.

As to the answer to how an organization would use them, we think that in a large organization, you would convene a multidisciplinary team with someone from IT, some clinical people, some nursing, some of the ancillary services, maybe medical records people. Try to bring all those stakeholders together. Some people know the answers to certain questions and know the nuances of those. In smaller organizations, you’d probably have to contact your EHR vendor or your IT consultant that’s helping you to get the answers to these questions.


It looks like some of the items could be incorporated into an RFP.

While we were doing this, we started out going to a lot of different healthcare provider organizations and talking to them about what they were doing and trying to understand what things were working and weren’t. Some of them, we realized that the EHR vendor really has to do these things. 

When we say something like, “The patient’s name should be on every screen and maybe it should have a picture of the patient,” the EHR vendor has to make that capability available. Then the organization has to implement that capability. You’re right; some of these things are very particular and only the vendors can do them.


How do you think the average hospital would do? Are these stretch goals, or would a hospital that’s competent in IT do fine?

Of the leading organizations — I think about the Scottsdale Institute members, for example, IHC, Mayo Clinic, and Partners in Boston, those kind of places –  I would expect they’re doing between 50 and 75 percent of the recommended practices. Of the 25 percent that they’re not doing, probably half of them they’ve consciously decided not to do them for one reason or another.

Some of these things are still a little bit controversial in terms of whether they’re really a good thing to do or whether an organization can really do them. For example, not allowing a user to open more than one chart for a patient on the same computer terminal. Most people would agree that that’s a good safety measure and would reduce wrong patient orders. But most clinicians would say, “I can’t survive if I can’t look at two charts at once.” 

Then it becomes a push-pull at the organizational level of whether the organization’s administration is going to make that kind of a proclamation to make that happen. If you look at a company like Epic, for example, they limit you to only opening five charts on one screen, but that’s a user-configurable parameter. You could say only one chart is allowed to be open on one screen.


A parallel would be hiring an external auditor to do a hospital IT audit. They evaluate their checklist of things that are important. You don’t have to do all of them, but since the report goes to your management, you would at least justify why you don’t. Would a rational use of the SAFER Guides be not necessarily checking every box, but at least recognizing that you should have a good reason for not checking them knowing they affect patient safety?

That’s a good way to say it. You need an explanation. If I were a CEO reading over the results and you were the IT person that came to me, I would want an explanation for why you think you should open more than one chart on it. You can say that the clinicians disagreed and we’ve decided to limit it to two. We could talk about that and decide whether that was reasonable or not. 

Intelligent people who are safety conscious could agree to disagree on certain of these items. But it’s something you definitely need to think about and understand why you’re doing it.


The beauty of an external IT audit report is the accountability. It seems as though like the audience that would be most interested, from an exposure from a patient care or legal liability standpoint, would be a hospital’s CEO.

I agree completely. We are really hoping that that’s the way they’re used. Either insurance companies will pick these up and ask organizations whether it’s doing this, or someone like the Joint Commission might take these up. 

We’re hoping that this is something that starts a conversation between what I’ll call the clinician, the EHR vendors, and leadership within your organization. That conversation is the key to improving the safety.


The IOM’s To Err is Human brought a lot of activity with regard to medical errors. The IOM’s EHR patient safety report was the genesis of the SAFER Guides. Will that make the idea easier to sell?

I would think that reasonable people would agree with these recommendations. The problem is that these recommendations generally are going to cost some extra money and some extra time.

Right now, with everyone thinking about Meaningful Use Stage 2 and ICD-10 coming up, I’m sorry to say that I think patient safety has been pushed to number three on the list. That is going to be the biggest struggle with these Guides and trying to get patient safety moved up to a high level of awareness within an organization.


Meaningful Use gets you a check, ICD-10 makes sure you keep getting checks, and patient safety doesn’t get you anything except possibly a lawsuit avoided. Is ONC going to market this like they do their other programs?

We’re hoping they’re going to do that. If they can keep their focus on this, I think that will happen. But like you said, this is really a cost avoidance thing. The organizations that seem to do the best in terms of meeting most of the recommended practices are those organizations that have had the biggest accidents. It’s like you don’t get religion until you need the religion.

In some of the organizations here in the Texas Medical Center after Hurricane Ike, they really got some newfound impetus to make sure they had better backup systems in place. They were ready for bad weather. It was Hurricane Alison that was like around year 2000 where we realized we couldn’t have our data centers in the basements any more in Texas Medical Center when they all flooded. It turned out the first floor of our buildings flooded, too. Now all of the hospitals in Texas Medical Center have their data centers at least on the third floor. 

It was interesting to me that when they had Hurricane Sandy in New York City that New York City still hadn’t learned that lesson about putting data centers and power generators and backup systems in the basement. Because when there’s a really big flood, the basements flood. It seems like we should be able to learn those things from other organizations. You shouldn’t have to experience them yourself. But for some reason, people always think that it couldn’t happen here. Like, do they think that New Orleans was a one-off, Houston was a one-off, and now you think New York City was a one-off? The important points are that these things can happen to anyone, anywhere.


What kind of resources would be required to complete the series and come up with a conclusion for an individual hospital?

It depends what you start with. We’ve had some pushback when we mentioned that you ought to have all your hardware systems backed up and you ought to have duplicate hardware. Sometimes that means two servers running in parallel and another one sitting off to the side, so when one of those that are running in parallel breaks, you have one to replace it. Some people say, “We can’t afford to have three of them on site all at one time.” We hear them say, “Our vendor promises 24-hour delivery.” A lot of it are those kinds of expenses and there are a lot of examples in the contingency planning about warm site backups, for example.

That’s just a matter of how much money you want to spend to get the kind of response and get the kind of availability that you think you need. You can always spend way too much money on any aspect of your process. You’ve certainly got to balance the amount of money you spend with the safety that you need. That’s a hard question to answer. 

The other way to answer it is, there are some other guides that would recommend that, for example, when you’re doing physician order entry that you ought to have all of your orders go through the physician order entry system. This idea of trying to get 30 or 60 percent of your orders through the order entry system — we think that sort of partial implementation of CPOE is a real danger because then you have some orders on paper and some on the computer system. 

That’s not really a cost in terms of money. That’s a cost in terms of the political capital of the leadership of the organization, of how much pressure they can put on the physicians — those final holdout physicians who aren’t using it. How much pressure can you put on them to incentivize them to use the system? There’s cost, both financial cost as well as a political cost.


If a hospital downloads the Guides, how much effort does it take for them to get far enough into the process to know where they stand?

In our preliminary evaluations, if you have either a very knowledgeable person or a group of knowledgeable people together, you can go through a Guide in under 30 minutes. There are nine Guides, so we’re talking four or five hours. If you took a half day, you could go through and get a pretty good feel for where you stood on these different items.


The obvious question without an obvious answer is that the government is paying incentives to get people use electronic health records. Now the government has issued a set of guidelines that says, “This is how you keep them safe,” and yet those factors are not tied to any incentive. Who’s supposed to run with this?

We’re not really sure right now what’s going to happen with them. Like I said, I’m placing my bets on insurance companies. The payers are the ones that can really enforce this. 

In one sense, the federal government is a payer. You could imagine CMS incorporating some of these recommendations in their Conditions of Participation and then making the Joint Commission responsible for looking at them. You could imagine public health departments saying something like this, or insurance companies saying, “We’re not going to approve this, or maybe we’ll incentivize you to use the SAFER Guides and give you a little more money if you have completed the SAFER Guides.”

We’re in the midst of negotiating with a lot of different organizations to try to get them to see who will step up and say, “This is a good idea. The people  we are working with ought to explain to us why they are or aren’t doing these kinds of things that are in the Guides”.


Are there other phases planned?

We have work planned, but we don’t have funding to do the work. Most of the criticisms we get fall into two categories. One is that there’s too much stuff on the Guides and they need to be shorter. The other criticism is, you left something out. When they say that we’ve left something out, they say, “We really need a Gguide for clinical documentation that would help people to understand how much copy-and-paste is allowable in a document.”

There’s also a lot of people who have been talking about a Guide for how to do  the patient engagement aspects of it — how should you configure your personal health record and what policies and procedures should go around the patient portal and their access to information. We certainly know there are at least two more Guides that would be very well received and are needed, but right now there’s no funding to develop them.


Do you have any final thoughts?

I would strongly encourage organizations to take a look at these Guides. They can really help an organization understand where they are and understand what the issues are.

A lot of people think that they’re unique and that things that they hear about don’t apply to them. When they see these Guides, they’ll realize that a lot of people are going through and struggling with these same issues. The leading organizations have pretty well come together and decided that backups are a good idea, for example, or physician order entry is a good idea. An organization would learn a lot by going through the Guides and seeing where they stand.

HIStalk Interviews Alan Rosenstein, MD, Disruptive Physician Behavior Consultant

January 27, 2014 Interviews 1 Comment

Alan Rosenstein MD, MBA is an educator and consultant in disruptive physician behavior. He welcomes contact by email.

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Tell me about yourself and what you do.

I’m a physician. I also have an MBA. I still do a clinical practice in internal medicine a couple of days a week. I do a lot of consulting work around care management.

One of my other positions is being medical director for a company called Physician Wellness Services, which is in Minneapolis, although most of my career has been involved on getting physicians around best practice care.


You’ve done a lot of work with disruptive physician behavior. How is that defined or evidenced?

I got into this as vice president and medical director for the VHA West Coast. We would always look at how we could help the medical directors focus on the issues that they think are important. The usual span of issues are quality of care, cost of care, and physician relationships with the hospital. 

I started noting that they were putting down disruptive behavior as one of their key issues. This really got exacerbated during the nursing shortage. That’s when I started the original survey on what is disruptive behavior? Are you witnessing it? Who’s doing it? Where is it occurring? That led to all the research about how significant an issue it is and then what we can do about it.

We describe disruptive behavior as any inappropriate behavior that can negatively impact patient care. That’s the simplest definition.


When you look at other professions, are physicians more likely to be disruptive, or it just more easily perceived because of the work environment they practice in?

It’s a combination of both. There are certain personality traits that lead people to go to medical school. It’s very competitive. They’re very ego-centric. During the medical school process, you’re taught very autocratic, independent, autonomous types of behavior. Physicians give orders. There is that personality that’s built in. 

Healthcare is a very hierarchical system. Physicians are on top of the totem pole. They’ve usually had their free way in giving orders and not taking any responsibility for their actions, although their actions are really aimed at best patient care. 

That in combination with the fact it’s a really stressful environment. In fact, if you look at where disruptive behaviors occur most frequently, it’s in either stressful areas — such as surgery, the emergency room, or OB — or in very stressful situations where the patient is having a negative outcome or the severity is increasing and they’re taking a turn for the worse and the physician needs to get involved. Sometimes they don’t do that in the most cordial manner.


In my experience , physicians who staff perceive as problematic and prone to explosive tempers are often respectful to their patients and even have great bedside manner.

I’m not sure they have great bedside manner with the patients. I think their intent is 100 percent, “I want to do the best for you, and in a crisis situation, I’m the one who knows best and I really need to take control.” That’s all appropriate, but many of these physicians are not good. 

in our research and others, we’ve shown that three to five percent of physicians — and nurses, actually — are truly disruptive. This can have a significant impact on the organization. But what we also found is that 40 to 45 percent of them are ineffective communicators. If you go back to that medical school, you’re trained in technology, you’re trained in knowledge competency, but you’re not trained in personal skill development. 

Now with healthcare being so complex, there’s many physicians in on a case, many other providers who are not physicians. The physician needs to better communicate and coordinate with them and also to present it effectively to the patient. 

I’m not sure that they have the best bedside manner, but they certainly are doing it with the intent of, “I need to take control.”


Is that behavior rewarded more readily for certain specialties, like cardiothoracic surgeons versus pediatricians?

Why do people act disruptively? First of all, many people act disruptively and they don’t even know they’re doing it because they don’t understand the downstream effect. A lot of the research has shown there’s a significant downstream effect where patient care is actually compromised.

They’re acting disruptively because they need to take control. They feel like they need to give the orders and get the best patient outcome. They’re doing it to try to provide best patient care, but they don’t realize what they’re doing or how it’s impacting, or most importantly, the long-term impact of what they’ve done. 

Eventually it gets to the point where you antagonize a person so much … in the short term, they’ll hopefully do what you’re asking them to do, but moving further down after the crisis, they don’t want to communicate with you any more. These communication gaps lead to problems with the patient outcomes of care.


Does medical training encourage or at least support disruptive behavior? Do you see that changing as newer generations of practitioners emerge who have been trained more as a team member rather than a single player?

Yes, absolutely. What we’re finding right now in medical schools is that they’re beginning to realize how important personal skills, communication skills, and teamwork skills are. 

Three things are happening. One is the MCAT, which is the Medical College Admission Test. They’re now posing more questions on the humanities, not just math and science. Two, as far as the people who are majoring, they used to major in chemistry or biology, now they’re looking for people who major in sociology and philosophy. Three, and most importantly, a lot of the more progressive medical schools are beginning to teach communication, collaboration, and personal skills during the freshman year of medical school to get away from this autocratic or independent behavior.


For physicians trained under that different model that no longer applies, it must be difficult when hospitals are acquiring practices, exercising more control in ACO-type arrangements, and mandating use of EHR systems that impose standardized care guidelines and require doctors to document themselves in ways that don’t benefit them. Does that feeling of loss of control elicit disruptive behavior?

Absolutely. One of the things that I talk about is why do people behave the way they do. I talk about the internal things. Age — those different values and attitudes based on your age and your generation. There are gender differences between men and women in how they view stress and how they handle stress. There are differences from culture and ethnicity, power, issues related to gender, issues related to dominance. Then there’s all the stuff from your life, upbringing, what you’ve been exposed to.

Those are the internal factors. Those can be addressed, maybe by sensitivity training or communication skills training. 

The external events — one of them you hit on — is from healthcare reform and initiatives and the electronic medical record. There’s now more and more pressure on providers, not just physicians, to be able to demonstrate and document good value care based on what other people think, not necessarily what they think. More adherence to guidelines telling you what you can and you cannot do. Taking people away from the bedside, spending more and more time on fulfilling all the requirements of the documentation. That gets everybody very frustrated because they just want to practice good care. 

One of the key concerns right now is the significant amount of stress, burnout, and frustration that’s hitting our physician workforce as well as others. A lot of them are trying to change jobs, get out of the profession, or retire early. That’s a real issue right now, because we are — if not currently, tomorrow — going to have a workforce shortage. 

One of the things that organizations need to do as they acquire physician practices and as they get them to adhere and be compliant with their protocols, their electronic medical record — they have to work with them to help them bring them up as a precious resource and not tell them, “This is what you have to do or else.”


What tips would you have for CIOs and CMIOs on the most constructive way to deal with physicians, especially those who have a reputation of being disruptive or resistant?

On the global level, physicians needs to understand why you’re asking them to do certain things. You need to raise the business case of why reducing variation and improving efficiency is going to get you the best patient outcome. That’s what you really want in the end, whether it’s a quality issue, whether it’s a cost issue, or whether it’s a satisfaction issue. Our goal is to make the patients get the best value out of a healthcare interaction and no one, no matter where they’re coming from, is going to say that’s not an appropriate goal. So you need to set the business case.

The second thing is you need to talk about what protocols and what enhancements you have, either technological or care management, and explain to them why we’re doing this — the idea that you reduce variation, we’re trying to do best-practice care, this will give you the best practice outcome. 

The most important thing is they want us to sit down and talk to them and listen. One of the frustrations from physicians is, “I have a concern, I have a problem, I have an issue, but no one is taking the time to talk to me about what my individual concerns are.” 

One of the key steps is that you need to sit down and talk to the physicians and find out what their resistance is based on what their barriers are. If you can potentially address some of those barriers, that’s something that the organization really needs to do. 

The last piece is that besides the business case and the support, you want to provide ongoing training. When you implement or you go live, make sure that you have these work groups that are readily available to help the physician get through what they really need to get through.


Pushback against systems like CPOE seems to have lessened. Are people learning how to deal more constructively with physicians or are physicians just resigned that they have to do it?

A combination of both. People are being resigned. Remember, for physicians, it’s not just the inpatient record, it’s also the office record. With Meaningful Use and with billing, you need to get into the electronic, so there is a business reason for them. I think the technology is there.

Certainly with the newer physicians who were brought up on technology, this is not an issue. It’s mostly the physicians who have been in practice for 20 to 30 years. They’re very used to their ways of doing things and don’t understand why they need to change. With the growing need that everybody is going to have to be up and running on electronic medical records, the physicians are recognizing that this is something they really need to participate in. 

The organizations do realize this, and as they implement these new medical records, they are very concerned about getting them on board and doing the appropriate training.


Do you have any final thoughts?

Part of it is the electronic medical record and part of it is the way the physicians behave. Physicians are a precious resource. I really do believe that all they really want to do is to do their job. Everything seems to get in the way, and some of those things are right.

Reducing variation, improving efficiency and productivity, and maximizing best patient outcomes is an absolute right thing to do. But I think organizations need to recognize that physicians are frustrated, they’re angry, they’re burned out, and they’re stressed. They need to spend more time in working with the physicians to prevent the inappropriate and truly disruptive behaviors, which can have a profound, negative impact on the organization.

HIStalk Interviews John Kass, VP of Healthcare Strategy, Bottomline Technologies

January 24, 2014 Interviews No Comments

John Kass is vice president of healthcare strategy and business development for Bottomline Technologies of Portsmouth, NH.


Tell me about yourself and the company.

Our go-to-market strategy is twofold, both on the direct front and as well working through Tier 1 ECM vendors. As healthcare changes and there’s a lot of consolidation in the market, we’re seeing a movement toward procurement being something that they want to simplify in that supply chain. 

I spent four and a half years at Hyland Software prior to coming to Bottomline. We were taking many people from paper to electronic and linking that information into the electronic medical record. But one of the things that really stood out is that paper has been holding back the power of ECM for quite some time. 

Logical Ink was an e-capture, mobile capture, e-data solution. There was a lot more you could get out of paper and changing the process was key. We signed a private label partnership with Hyland Software. Really being able to go back to customers that I’ve worked with for quite some time and improve the value in technology they’ve already purchased.


Describe what Logical Ink does and how you incorporated that acquisition into the product line.

We acquired that technology several years back. It was called Logical Progression. Chris Joyce, who is our director of product development here today, is the developer of the solution.

When Chris invented Logical Progression, the market looked very different. The biggest change is that we’re seeing much more connected healthcare brought on by Meaningful Use. We’re seeing EMR adoption growing. The goal is, how do we create a longitudinal view into the patient?

What’s really changed is, when I came on board, taking the focus around the strategy of… this is something that ECM became a very natural marriage. The product is a much more connected solution today. It’s an enterprise, what we call a standardized one capture platform, any downstream system. In addition to moving and capturing the form, we have the ability to capture discrete data elements in the form and map that downstream. You can have one encounter, capture that information, send it to a Hyland Software OnBase, link that to an electronic medical record, and simultaneously send discrete elements of data down to a population health system or another system discretely. 

The other change is that four years ago, solutions like the iPad did not exist. They’ve revolutionized the way we interact with technology in a way that I can hand my 70-year-old mother an iPad and she immediately gets it. We’ve got a native iPad application. We’re also on Windows. The ability to have devices that are much affordable and usability being much higher has changed the game in the last several years.


Can you explain what Hyland OnBase does and how you tie into it?

It stands for “one database.” OnBase is an enterprise content management system. In the patient-related world, there are things inside of that electronic medical record that you’re capturing as discrete data elements, but there are all kinds of things that generate from paper or other people’s systems that have no meaning to it. It’s called unstructured content.

Hyland can quickly bring that content in, capture it, and then put meta-data or key words around that content. Once they add meaning to that content, they have some very slick opportunities to link that contextually into an electronic medical record, or even on the ERP side in the non-healthcare world.

One of the things that we saw was having the ability to not have to scan physical paper into a physical device. There are too many documents going down to HIM to batch scan, so the burden on HIM is still very, very heavy. The goal is, how do we decentralize the capture in a seamless way and how do we optimize the ability to ultimately know what that form type is, because we’re starting electronic in a way that’s very meaningful with the patient?  

We can simplify all of that, the scan queues and hiring people to work and help index that content. We can immediately send that to OnBase through an API and they can immediately place those hyperlinks contextually within the electronic medical record. When you look at it from a workflow and a patient engagement perspective, it’s a game-changer in how you interact with that content.


HIM does batch scanning, indexing, and QA to link the scanning of paper. Is electronic mobile capture a better way, and will that process eventually go away?

You’re seeing quite a few trends in the industry. I’ll categorize it in a couple of ways.

There’s always going to be that external content. A patient walks in with pieces of paper that originated in another facility. I call that third-party content. We’re seeing that as an area that you still typically have to scan. If you’re a large IDN, you’re seeing a lot of the banks starting to offer the ability to scan that for you and create an index file as a value-added service. That’s number one.

We’re seeing more things captured discretely as a result of Meaningful Use, tying EMR adoption to reimbursement. But more importantly, certain stages of Meaningful Use are required. In other words, the government said these EMRs need to be certified and they have to do certain things. That’s certainly gotten rid of some of the paper.

There’s that remaining paper. There’s that remaining interaction. Those are things that start inside your own facility. It’s the consents. It’s the patient history. It’s the ABNs. It’s sometimes taking a photo and being able to embed that photo and have the patient or clinicians fill out information about that photo. Prior to Logical Ink, you would have to literally plug a camera into a USB, go out and find that photo, and attach it and attach meaning. With Logical Ink on an iPad, a clinician can take a photo with the embedded camera, embed that photo instantaneously in a form, and fill out information or have the patient fill out information. When we hit submit, it can automatically be linked into the downstream system.


Do you think that the increased use of electronic medical records has expanded rather than contracted the content management market?

Certainly it has. There is absolutely no doubt about it that. There was a mandate, there was reimbursement tied to it, and there was a timeline. These were all very compelling events to moving people forward. It’s an impetus to a range of people adopting technology at different times. We’ve seen an industry movement across the board through this mandate that’s been very big. 

Certainly with the enterprise content management piece being a component … I always tell people, your goal isn’t to buy an enterprise content management system and an EMR. Your goal is a longitudinal record of the patient where you can see every action and encounter through one viewer. So Epic becomes that viewer, for example, or Cerner. But what’s great about ECM with the embedded nature of it, when you’re viewing some of that content through the core EMR, many times folks don’t even realize that the ECM portion of that is not just an extension of the actual core system.


Thinking about gaps in functionality or gaps in usage that electronic medical record systems have, what can automated or online forms add?

HIMSS came out recently and talked about with so many EMR vendors moving so quickly to try and fill the mandates of the different stages of Meaningful Use, while they focused on the functionality, usability’s probably something that has not taken a front seat given the time.

The other thing we’re hearing is that early productivity reports are showing that with clinicians having to do so much charting in front of the patient, productivity is going down. As you can imagine, part of diagnosing a patient is observing that patient. One of the things that we have been focusing on is the ability to have the patients fill out on an iPad, for example, all of these required forms. That’s unvalidated data at that point.

Now imagine as you walk into your doctor, having the doctor on an iPad asking you questions and updating and editing that information to validate that. Then capturing in that one encounter, moving the form into an ECM solution, but moving the data elements and mapping them discretely into the electronic medical record. We see that that is absolutely key.

The other thing is that while the EMR encompasses probably 80 percent of the overall enterprise technology around clinical and financial applications, there’s all kinds of “ologies” and patient disease management systems. People talk about data silos in healthcare. I would argue that what we really have is vendor silos. We’ve become that unified front end despite where the information is going with a simplified front end that they’re used to, applications like a Windows tablet or an iPad. We’ve focused on those areas to help augment and improve the usability and the optimized workflow.


What are some ways that customers are using your technology to improve their core hospital systems?

We’ve got a facility in California that is capturing various forms, but also simultaneously feeding discrete data from Logical Ink right into their disease management system, their population health system. They saw an application that we believe is a differentiator. We’re not just capturing signatures on forms — we’re having a very interactive process with that data. We came up with a concept of you have one encounter, so you capture once with the ability to push to any downstream system.

This is a paradigm shift for them. Before, they were scanning that piece of paper and somebody was entering the discrete information manually into a system. The ability to automate that process in a way that happens very natural with the interaction was a real game-changer from both a workflow time to get information in and certainly from a cost perspective, removing the manual process of having to hire people to manually do that.


Do you have some ideas about best practices for improving the satisfaction of patients with the intake process?

There are areas that you’ll go into, a very static patient access area, where there are stations of people working. You literally are going to go in there, check in, and sign all your forms. The fact that our solution can be a desktop solution, can be a web solution or can be a tablet solution means that we offer a very, very compelling licensing model where we don’t differentiate. A device is a device. It gives you the opportunity to use many different platforms for many different uses. 

Where things become very compelling is healthcare – unlike, for example, an accounting job, where you log in and you may not move all day long — many healthcare workers are roaming throughout the facility for different encounters and what have you. The ability to take what used to be maybe a computer on wheels with a scanner on a cart, wheeling that around, physically having to take a packet of 10 forms and physically putting 10 forms through a physical device called a scanner, is a lot of work. Sometimes that gets in between you and the patient. 

If you’re out there wheeling that cart around and your role is to wheel that around all day, changing that from walking with an iPad, scanning a patient’s wrist band, having the ability to pull that patient, pack it up because we’ve got all the integration on the back end with the ECM and all of the different document types and the levels of those document types already being pre-set to the EMR, your ability to walk in very pervasively and have that ability to capture things in a pervasive or untethered way is something that again is a paradigm shift. It allows people to be much more natural and upright and  a tablet doesn’t get in the way between you and the patient.

Most people didn’t see the potential for enterprise use of tablets when the iPad came out, but now everybody wants to use them. WiFi connections are decent and tablets are cheap. Will more opportunities come up?

I think so. Like you said, we’ve got bandwidth today. We’ve got devices. I look at an iPad as a productivity tool, more an appliance than a computer. That’s where you can draw a line in the sand. It really does simplify the way in which you interact with technology, for example. 

Four years ago, you look at where bandwidth was. We had no Meaningful Use. You were talking about a tablet that might cost $1,500 and it really wasn’t enabled for the touch experience. The market wasn’t there to take advantage of the applications.

Fast forward to today, looking at being linked to those Tier 1 vendors, looking at really tying and anchoring into investments that have been made there, and putting the engine behind the ECM in a way that paper has held ECM down for years. If you look at all of those factors, we’re at a time where the market’s there.

People are using these tablets in their personal lives. There’s a very consistent, constant look and feel. People don’t want to use a device at work that’s more of a barrier than the one they use at home to look up an article on the Web. We believe that we’ve bridged that gap in a way that the same simple tools they use in their personal life, they can absolutely start to use in their professional life.


What are the company’s plans for healthcare over the next few years?

The timing is right. The market is right. We’ve got the right platform. We think we’ve got the right strategy. We want to be heads-down focused. The company is always looking for potential acquisitions, so that’s something that I would say is ongoing. But we’re looking to do the right thing for the right time and the right reasons. I’ve been on board a year. 

I’ve gotten very, very comfortable in my role and I’m at a point where I feel like we’re optimizing some of the things that we’ve done over the last year. For the time being, we want to keep focused on the opportunity we have right in front of us.

HIStalk Interviews Lyman Garniss, Pathology Project Director, Partners HealthCare

January 21, 2014 Interviews 2 Comments

Lyman Garniss is project director for Partners Enterprise Pathology at Partners HealthCare of Boston, MA. He was interviewed by Lorre Wisham of HIStalk

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Tell me about yourself and the organization.

I’ve been here at MGH and Partners for 25 years this month, primarily working with the clinical laboratories and anatomic pathology folks at the MGH. However, in the past year, I’ve been working with Partners HealthCare, the larger system, to roll out Sunquest lab and some of the blood bank systems and other products across all of Partners and also integrating that with Epic. 

Epic is going in across all of Partners, and everyone’s getting a standardized HIS. We’re also at the same time moving everyone to a standardized LIS.


What are your thoughts about the future of genetics and genomics in terms of data and whether it comes from the HIS or the LIS?

The LIS really needs to own that space. It’s where the data is generated today. At least 70 percent of the data in a patient’s medical record in the HIS is coming from pathology, from the labs, from anatomic pathology, and blood bank. There’s some 10 billion lab tests that are performed in the US each year. We produce a ton of that data. 

It’s going to get much larger with the genetic information, proteomics, and all the variant information that goes along with those data points. There’s no easy way to manage that today. The lab owns the specimens and some of the reporting of that, but they really need to own the data itself, the mining of that data, and the curation of the information related to the genetic variance and the proteomic data.


You’re saying lab needs to own it, which suggests they don’t now. What has to happen?

It’s a collaboration of the LIS vendors, companies like InterSystems or IBM that manage large data sets well, as well folks from the academic and medical area. A three-way collaboration that has to happen.

The lab information vendor knows the lab space really well and the lab processing and the specimen processing, but their niche really isn’t large data sets and mining large data sets. That’s where they’ll need some help from some of the large database companies, as well as some input and advice and boots on the ground from some of the folks that are actually performing these tests.


You mentioned Epic. What do commercial electronic medical record systems have to do long term to keep up with medicine on the lab side?

The breadth and scope of HIS vendors are so large that it’s very difficult, if not impossible, for them to be experts or to be best of-breed in every single area or every single domain that they touch. They may have some expertise in specific areas, but they would have to invest a lot of money in the lab space and really be focused on that. It’s difficult for large vendors like Cerner and Siemens and Epic to be experts at the lab and also manage that large breadth and scope. Their domain is huge.


Why are you not choosing to implement Epic’s Beaker LIS instead of Sunquest?

There’s a number of reasons for that. The first one is the Beaker product just doesn’t seem mature enough for our needs. That’s one data point. The second data point is we have a rich history of collaboration with Sunquest. We’re working on integration between the laboratory system and the anatomic pathology system. 

The walls between AP and CP are breaking down. The type of work that is happening in the lab information system is starting to look, in some instances, more like anatomic pathology — large, rich textual reports that the CP system doesn’t do well but AP does well. The reverse is true. We’re doing more instrumentation and instrument testing on the anatomic pathology side. The AP systems really don’t manage instrumentation and stuff well, where the lab system does.

Sunquest is moving forward with us on breaking those walls down so that the integration between AP and LIS, the APLS, and the LIS is much more robust and streamlined, much more integrated.


What do you think a hospital CIO should know about lab or pathology informatics?

I was invited to speak to several different groups of my peers here at Partners.The message that I was trying to get across to folks in IS and to other areas is that, again, we’re providing 70 to 75 percent of the data that’s in that HIS. The lab information system is large, it’s complex, and we’re producing a lot of data, a lot of rich data. We’re going to continue to produce even more of it in the future.


How are you using your EMR for clinical decision support to guide physicians in ordering labs?

Poorly. [laughs] We have a current provider order entry system. It’s a homegrown system. We are able, with that homegrown system, to customize it to some degree to help steer clinician ordering away from expensive send-out tests.

I’ll give you an example. We show dollar signs next to the test. We don’t actually say how much it costs, but we provide alternative tests that would be cheaper to keep the costs down, especially as we move towards that ACO market. We’re starting to look on the lab side how to steer clinicians towards tests that may be just as effective, but may be less expensive. Epic doesn’t really do that today.


Clinical analytics for population health management is a hot topic. What is Partners doing to standardized data and enable better reporting?

The first step is moving to Epic. I believe that the folks at Partners are working with Epic to work more on some of those outcome models and patient care models moving forward.


How do you see personalized medicine based on patient genomics moving into everyday practice?

It has to start with the discrete data that’s in the laboratory. We can’t possibly send all the genetic information to the HIS. It would be overwhelming for the clinicians. It would be overwhelming for the HIS system itself. 

The role of the LIS vendor is going to be looking at all these rich data sets and mining, looking for patterns for outcomes to figure out both on the CP side for predicting potential disease states based on genetic variance, but also on the anatomic pathology side, looking at outcomes and survivability for specific types of cancer to figure out.

It’s probably best if I use an example. Something like pancreatic cancer, where the survival rates of that are horrific. Once you’re diagnosed with pancreatic cancer, usually you have weeks or months to live. But there’s probably people that survive longer than others, and we have their specimens. We have a rich biorepository of anatomic pathology specimens, where we can look at what’s the genetic variance in a particular type of that outcome versus somebody that didn’t survive as long. Then we can start targeting therapies based on that. 

The example that everyone’s using today is the HER2. There were one or two treatments for breast cancer in women. Depending upon the treatment, sometimes it killed the patient quicker, but sometimes it cured them. But there was no rhyme or reason until folks figured out that we could base the therapy on specific genetic markers in the tumors.

HER2 is a perfect example and more and more of those examples are going to come forward. But the only way to find those models or find those differences is to be able to mine the data. The laboratory owns that data. It doesn’t reside in the HIS. Mining of that data has to happen in the LIS space.


How can the average hospital involve the lab people in their EMR decisions and setup?

I have attended the Sunquest User Group for many years. There’s now Epic roundtables at SUG, the Sunquest User Group. Those have been very enlightening. 

What we’ve seen at those meetings are basically two camps of folks. There’s folks that Epic was installed at their site and the laboratory was not involved. In speaking with those lab folks now, Epic has become a nightmare for them because they were not involved with a lot of the decision-making process. They don’t have access to a lot of the way that the system was designed or built. Supporting the lab information system and integration with Epic has been extremely problematic for those sites where lab was not involved up front and early with the HIS vendor with that integration and testing process.

Then there’s the other camp, where the LIS folks — both IT and the actual people that are doing the science in the laboratories — were involved early on with the HIS implementation. Those folks are happy with Epic. They’re happy with their HIS and things are going extremely well. We learned from that at Partners early on. My team and others on the lab side are working really closely with the Epic folks in installing the systems here and doing the integration work. It’s been absolutely fabulous. A lot of decisions are being made that make sense for both sides of the equation. Again, we’re providing 70 to 75 percent of the data that’s in the HIS. The lab has to be involved early on with the design, setup, and decision-making process that goes on with the HIS build.


How is Partners exchanging information with other facilities outside of your group?

We’re part of the Mass HIway. That interchange is still being rolled out. I wouldn’t say it’s in its infancy, but it’s in its adolescence. 

We send quite a bit of information to the Mass HIway. We do all of our state and city reporting to the Mass HIway. Data that has to go to the state for state-required reporting, like some of the blood management things and the microbe reporting.

Partners HealthCare provided the seed money for an exchange years ago called NEHI. It was for medical centers in the New England area to exchange information with the insurance companies. We’ve been doing that for years. Instead of just having the Partners facilities manage that, we invited other institutions as well because we thought it would be in everyone’s best interest to share the cost of that insurance exchange with them.


What are your biggest challenges and opportunities at Partners over the next year?

There’s a few things that we’re working on. Expanding the LIS into areas that they typically haven’t worked in. One is research and managing the research specimen flow; the second is biorepositories. There’s a lot of rich specimens flowing through our systems, but we’re not able to track cohorts or manage consented patients in the LIS, so we don’t know when their specimens are flowing through the system to be able to move those specimens elsewhere or inform a researcher that specific, unique specimens are available. We’re throwing tons of these specimens away and they’re actually quite valuable in some instances. The biorepository area is something that we’re working with the LIS vendors on and we’ll expand in the future.

And then of course the genetics, genomics, and proteomics, and the rich data set … curating the data that goes along with those. The variant information. It’s a huge challenge for all of the institutions that are doing genetic testing to be able to track and update the most recent information about specific genes or gene variants. It’s a huge challenge for folks. There’s no straightforward tool sets that manage that rich data set today. It’s one of those things that the lab, the LIS needs to own and need to expand their role in.

HIStalk Interviews Adam Cheriff, MD, CMIO, Weill Cornell Physicians

January 20, 2014 Interviews 2 Comments

Adam Cheriff, MD, is chief medical information officer of Weill Cornell Physicians of New York, NY.

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Tell me about yourself and the organization.

I am the chief medical information officer for Weill Cornell Physicians. I’m a part-time internist, the rest of the time responsible for the clinical health information technology and clinical operations for our physician organization. Weill Cornell Physicians is 950 multi-specialty faculty physicians associated with New York-Presbyterian Hospital.


You recently went live with Epic. How’s that going and what are the most important lessons that you’ve learned so far?

We have been an Epic ambulatory customer for many, many years, since 2001. We have a great deal of experience with ambulatory clinicals. What we did most recently was convert our legacy practice management system, which had been GE-IDX, to Epic. We’re very happy with how that’s gone.

We gave it a lot of careful consideration as to what the motivations were for doing it. For us, it was really about trying to consolidate onto a single platform for our administrative and clinical systems; the patient experience and improving it via self service; and lowering the training burden for our staff and faculty. We had an eye towards the future, where we knew we were going to have to do more advanced analytics, and being able to seamlessly move between the clinical and the administrative was a big deal. We had a hope that in doing this that we would lower some of our long-term operating costs.

We went into it with what we thought was good justification. I thought we were thoughtful in terms of how we restructured organizationally from an administrative business unit standpoint in order to support the implementation. That really was a lot of matrixing of the IT and clinical staff that knew the Epic clinicals and knew how to manage that relationship, the business office that were the core revenue cycle domain experts, and our finance office. I think that matrixing really helped a great deal.


Some organizations, particularly on the hospital side, have struggled with the conversion to Epic from a revenue cycle standpoint. What’s been your impact?

We feel very fortunate, obviously. I think the press seems to have a little bit of a selection bias in terms of seizing on, unfortunately, the missteps. I can completely see how these things would happen. They’re extremely complicated projects.

We have felt very, very fortunate about how things have gone. I should say that our implementation methodology may have predicted some of our success. Despite the fact that Epic would like to see organizations do this big bang — and I think that there are reasons for that in terms of not necessarily bleeding this out and being trapped in two worlds — we did this in a series of pilots leading up into a big bang. That gave us just enough experience with the new tools, so that with each phase of it, we got stronger.

The high-level summary of our financials is that for one cohort, we’re about six months into this. For the two-thirds of our business, we’re about three months, or one quarter, into this. We are 10 percent year to date increased in our receipts. Now it’s unfair to attribute that all to Epic, because obviously we have a lot of other growth initiatives. But if you look at it from the standpoint of what we budgeted in terms of anticipating that growth, we’re still three percent up, which you can fairly attribute to the Epic effect.

The main efficiencies that we’ve gained is that Epic is great in terms of transparency and accountability, for working charge edits and claim edits, and really has a great task management system to do that. Our pre-AR, we’re working much more aggressively than we were pre-Epic.


When you converged onto the single Epic platform, what goals and metrics did you hope for as an outcome?

We looked at the classic revenue cycle metrics. Those are all important. Days in AR , and this might be somewhat Epic-speak, but days in pre-AR as well, claim edits, denials.

Epic does a fairly good job of being prescribed and doing a fair bit of hand-holding with tools to be able to look at those metrics as you’re making the transition, even including some of the legacy practice management statistics as you make that implementation. We are also very interested not exclusively in the revenue cycle side, but also on the access and front-end side — registration quality, patient duplicates, the number of patients that make online appointments, our access metrics in terms of how long people have to wait to get appointments, and so forth.


When you mentioned patient self-service, were you primarily referring to self-scheduling?

Yes. Self-scheduling and online bill payment were the two features of MyChart that we were able to unlock with the conversion to practice management.


What kind of feedback do you get from patients?

It’s a little early for us to have amassed a lot of formal feedback. Anecdotally, we think that patients love it and that it is definitely helping our brand. Although I will say that given our marketplace in New York City, we have to keep up in that. Many of the other big academic centers are using similar if not identical platforms. Patients really like the convenience that is afforded in sectors other than healthcare. 

Culturally, from a physician organization standpoint, we still have a ways to go. While the consumer is definitely demanding it and the patients want it, the physicians are a little bit slow and guarded about the degree to which they’ll give open access to scheduling. But I think we will evolve.


You mentioned that Epic is part of your brand just as it was for Kaiser Permanente, who named their implementation HealthConnect. Do you see that as a competitive advantage and a way to enhance your brand with patients?

Yes. We did something similar right down to the name in that we branded MyChart as Weill Cornell Connect. The patient engagement strategy is so important. From a regulatory standpoint, it’s become increasingly important in terms of all the Meaningful Use objectives around engagement and how you need to communicate with the patient.

From a branding standpoint, the patients really do feel connected. Part of it is the transparency and the visibility of the record, which, of course is something else that the physicians slowly have to wrap their heads around.

But it’s really the interactivity. It’s the ability to, in an asynchronous way, reach out to the practice for all the things that people need to reach the office for. Not being on these endless phone queues is a real patient satisfier.


You mentioned that having both sides of the house on Epic gives you some new opportunities. What are you doing or what will you be doing in terms of analytics and population health management?

We are pretty energized about this. Clearly we’re moving from the phase where it’s less about the adoption of the technology, even to some extent less about optimization, although that is going to occur forever. It’s more about now that we have had critical massive adoption, what do we do with all this great data that we have been collecting? We, like most Epic clients, rely heavily on the relational model of Epic’s data, which is Clarity. We have pretty sophisticated report writers and business intelligence tools, including both Business Objects and Cognos, that sit on top of that. 

We are very eager to see where Epic continues to develop in this arena. They have done a good job of recognizing that in order for us to effectively manage populations, we’re going to need more than just the data that’s within Epic. The Epic data warehouse that they’re building towards that will allow us to take in outside claims data and patient satisfaction data is very intriguing to us.


Have you gained insights from having all that data available?

We engage in the same kinds of clinical outcomes and chronic disease management metrics that most large institutions engage in. We understand how our diabetics are being managed and our CHF patients and COPD and the chronic disease markers. 

We have struggled, like many organizations, to drill into that from a utilization and cost containment standpoint. That’s why it will be critical for us to start to marry those clinical data, which have become ubiquitous in our system, with the claims data that will be generating now that we have the practice management system.


How do you see practices changing both in terms of the changes prescribed by the healthcare environment and the availability of the technology like you’ve implemented?

Oh, boy, that’s a good one. The technology absolutely changes our culture and our practice patterns. I can give concrete examples over our life cycle. 

The first thing that the electronic health record did is it made us function more as a group model. We are a group. We’re a federated group of clinical departments. But sharing the single patient record with the focus changing from the provider’s record to the patient’s record was a real paradigm shift in the way that you can’t help but promote communication. That has promoted better outcomes. 

The next major paradigm shift was the rise of the patient portal, that level of transparency and really getting providers to understand that in many ways the patient owns the data and being as transparent with the results. The self-service model and the online scheduling. Even the rumblings of the OpenNotes project, where people will expose their clinical documentation. 

These are all things that are going to be profound drivers of the way we practice and probably will predict better outcomes because you’ll have a class of patients that’s much more engaged in their care.


Are you implementing more evidence-based medicine and standardized care protocols along the way?

We have. We have made use of fairly standard decision support tools that are available in Epic, particularly around Health Maintenance Rules. For certain populations of patients or certain chronic diseases, making sure that we have the data-driven schedule of what should be done for those patients. We use decision support alerts to support that. I think it’s been very effective, actually. We probably have, at this point, dozens of rules that are keeping track of that information.


Is there more interest, or could there be more interest, in patients taking a more active role in their healthcare and their health than they have previously?

Yes, because it’s more accessible. If you go back even just a few years pre-portal, it’s pretty difficult for patients to really access their information. What they’re left with is what they can absorb in a hurried clinical interaction, which is often exceedingly difficult for patients. As the word says, a portal is a window into what’s going on with them. 

The fact that we’ve been able to embed patient-friendly education that directs people to do further learning about their conditions, I really do. Where Epic is developing some of the tools that we’ve implemented is that for chronic diseases, that there are tools for patients to engage. Whether that’s blood glucose monitoring for the diabetic or blood pressure monitoring for the hypertensive, that’s a way for them to engage in their health and to promote that communication back with the provider.


If you look ahead two or three years, where do you see the most important IT-related priorities that will impact your organization?

It may have become a cliché at this point, but the past couple of years have really been about keeping up with regulation. Unfortunately I don’t see that necessarily dying down. Meaningful Use, ICD-10, and all these things that we really have to do. A lot of good that has come out of it, but in many ways, it has stifled innovation. 

The next couple of years are going to be about usability and trying to refine these user interfaces. Clearly interoperability is where we’re headed. The goals of some of this regulation is consistent with promoting the this interoperability, but many of us at the ground level have not seen that realized. T think that’s going to be incredibly important.

Locally, and this is true of many organizations like us, growth is going to be a big driver. The fact that we’re probably going to extend into a larger provider network to take care of larger populations, we’re going to have to find ways to spread our technology and to be reasonably agile about that.

HIStalk Interviews Laurie McGraw, CEO, Shareable Ink

January 15, 2014 Interviews 2 Comments

Laurie McGraw is president and CEO of Shareable Ink of Nashville, TN.

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Tell me about yourself and the company.

I’ve been in healthcare for 20 years. I started way back when at IDX in Burlington, Vermont. In the late ‘90s, they broke off a subsidiary called Channel Health. I was running development at the time. That got bought by Allscripts. I was part of the Allscripts team from 2000 up until the time that I left in January of last year. 

When I started at Allscripts, we had five customers doing the EMR. It was called EMR back then. When I left, it was a $1.5 billion company that was pretty large. Those 12 years were a blast, just an absolute blast for me. 

This past summer, I joined Shareable Ink. I am the CEO of Shareable Ink today. It is a young and vibrant company that was founded by a brilliant innovator named Steve Hau who took a common sense approach to doing clinical documentation.

Shareable Ink does clinical documentation and we do it really, really fast. We take existing paper forms, tag them, digitize them, and preserve workflows for physicians to document, Again, very efficiently, very fast. We have these analytic tools where people can get great insights from the data that they’ve put in and drive financial outcomes and quality improvements.


Part of the appeal of the digital ink option for data input was that CPOE adoption was pathetic and electronic physician documentation wasn’t common two or three years ago. Usage of those has improved. Is there still a need for an alternative form of input?

I think so. I’ve worked with physicians all these 20-plus years. I’ve been in front of hundreds of physicians, physician audiences from physician groups to hospitals to whatever. What I know is, physicians don’t hate technology. They don’t. They love technology.

But what they hate is they hate being slow. Everyone appreciates getting quality data at the point of care. They want all that information. They just hate being slow. 

With Shareable Ink, we can extend the investment that’s already been made in electronic health records, or we can just simply replace paper that still exists in lots of different places in the healthcare system. Just making that physician fast, it’s very valuable. People have already made significant investments in clinical technology, but when physicians are slow, there are a lot of things that need to be done to improve that for them.


Part of your value proposition is the concept of clinically rich documentation. Does the typical electronic medical record product support that?

Fundamentally, the answer is yes. Electronic health records — and I’ve worked on them for all 20 years — are good products. Whether it was ones that I had worked on previously or other companies who are putting out electronic health records, they’re fundamentally good products.

Where the electronic health record falls short for physicians, in terms of what I’ve seen, is where they start to slow the physician down. It doesn’t mirror workflows that previously worked, either in the paper world or in the newly adopted electronic world. That’s where I see the need to either augment or go back to workflows that were previously really fast.

I know I keep saying fast, fast, fast as a theme here. I say that because all of the benefits of electronic health records, everybody still wants them. Many, many organizations are achieving them. But they’re still falling short. Everything in healthcare is driving towards more need for data at the point of care. That’s where we’re focused.


Is it common for hospitals that have successfully implemented CPOE and clinical documentation for physicians to add a product like Shareable Ink or do they usually use it before they are ready to adopt those EMR tools?

It’s pretty rare that an organization is completely on paper. Usually Shareable Ink is in a place that is supplementing some already automated clinical workflows. We’re either extending an EHR investment that’s already been made by some specific workflows in a particular specialty or we’re replacing some existing paper forms that are still being used because those particular paper forms capture all the data in a really efficient manner for the clinician. 

For example, we do a lot of work in the area of anesthesia, where a lot of paper still exists. We’re replacing the paper. But in many other places, we are replacing paper where clinical technology already exists.


I made the observation when I interviewed Steve Hau four years ago that the higher you go up the specialization chain of physicians, the more reliant they are on very specific forms rather than the general documentation that an internist might us. What areas of the hospital are most reliant on those specialized forms that don’t translate well to an EMR?

A couple of years ago, I would have said specifically areas like cardiology or orthopedics or something of that nature. The discussions that I’m having today, it’s back to areas — surprisingly to me — like primary care, where, quite frankly, there’s a lot of documentation needs, but organizations are still needing to supplement what their primary care physicians are doing because the speed at which they need to document in the electronic health record isn’t fast enough because of the tools that they’re using. They’re going back to things like paper to supplement it and scanning it in, or they’re looking at hiring scribes to help those physicians meet their productivity objectives. 

The premise of “the more specialized you are, the more likely that there are paper forms to supplement that” … it’s not that that is not true, it’s just that there are more general areas like primary care where there still is a lot of paper because of the productivity needs of those clinicians.


Hospitals put in systems, find them to be a burden to productivity, and then come to you for an alternative?

Absolutely. There’s opportunity to extend that electronic health record. The investment has been made and everybody is driving their quality programs based on what they can get out of their electronic health records, but they have to also meet certain productivity objectives within their organization because the volumes for these physicians and clinicians are increasing. 

Shareable Ink can help expand an electronic health record in those areas where you hear of physician dissatisfaction with their electronic health records. That’s a pretty common complaint. The reason is rarely because they don’t believe in the electronic health record. It’s always because of the speed issues and the productivity issues or how they’re encumbered because of using the technology. They just feel it slows them down. I’ve heard this directly for such a long period of time.


Most of the new hospital EMR sales are by either Cerner or Epic. What are some examples of integrating the Shareable Ink offering into those products?

We can integrate through interfaces so we can provide data into those systems, whether they’re Cerner or Epic, in the hospital. We have partnerships with vendors like Allscripts, like Greenway, where we use their open APIs to send discrete data into the electronic health record. 

Those are ways that we can extend the electronic health record investments organizations have made with those vendors. We’ll be looking to do more extensions like that in the coming year.


For a company like Epic that hasn’t offered too many hooks into their application, what would be a functional view of an Epic hospital implementing Shareable Ink?

We’re exploring those workflows now. Shareable Ink is a young company, but where we’ve implemented today is in specific areas where we’re replacing paper forms that already exist. They go into a McKesson system, a Cerner system, through a document viewer within that other system. Shareable Ink preserves the view of the form that has been filled out as well as all of the discrete data that is under the covers of that paper form.


There’s a lot of richness involved with what you can write on a piece of paper, even including the way you write it, where you write it, or what you draw as a picture. Are people realizing that that sterility of a set of fields that are extracted into an electronic medical record may lose some of the patient context?

I think that is a problem. I think that is an issue. I believe Shareable Ink can help solve some of that by bringing some of that richness back.

I’ve seen the discussions and been in the discussions with physicians who feel like they’re looking at a SOAP note or a clinician note that may be complete, but it’s so sterile they’ve blocked all the nuances of the care that was provided to the patient. Can Shareable Ink help in that regard? Sure, it can help — but not necessarily in the same ways as speech – through different pictures or notations or things of that nature. But I don’t want to pretend for a second that getting to that specific discrete data is still incredibly important for all of the quality metrics and everything else that an organization’s trying to drive toward.


Can you hand forms that have been turned into Shareable Ink to someone with no training and turn them loose?

You can. It is a stretch to say no training. There is some training required, but it is simple training. 

With Shareable Ink, when clinicians adopt it, they are not clearing their schedules. They’re not reducing their patient volumes to then adopt this additional clinical technology. What they’re doing is taking some additional time. The paper metaphor or what they’re used to with a form — that’s the workflow that’s preserved. 

It’s already a workflow that they’re familiar with. Now they’re just doing it on an iPad, or that same form on an iPad, or they’re doing it with a digital pen.


How is Meaningful Use affecting your business?

I’m hoping that it will increase the need for tools from Shareable Ink because Meaningful Use means a whole lot of additional data is required at the point of care. Just simply voice recognition into blobs of text is not going to be enough in terms of all the data that’s required for Meaningful Use. 

Shareable Ink can provide that additional rich data at the point of care while still keeping that clinician very, very fast. I’m expecting Shareable Ink to again be a great addition in complement to the EHRs that are out there.


Do you have any final thoughts?

I’ve spent 20 years in healthcare. While it has been awesome in terms of paving the clinical information highway, today what I see is that we spend a lot of time on all of the challenges that are out there: adoption, physicians being slow, needing better data, the challenges of Meaningful Use and ICD 10. What all that points to is really the need for better data at the point of care. 

I am optimistic that what we’re doing at Shareable Ink in terms of providing that rich data at the point of care and by doing clinical documentation in a way that is fast and efficient for the physician that we’ll be able to deliver on the promise of data-driven healthcare.

HIStalk Interviews Chuck Podesta, SVP/CIO, Fletcher Allen Health Care

January 13, 2014 Interviews No Comments

Chuck Podesta is SVP/CIO of Fletcher Allen Health Care of Burlington, VT.

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What lessons did you learn as your single hospital expanded into a health system?

I’ve worked with systems in the past, so I was prepared from a due diligence standpoint to understand what we were getting into. The interesting thing has been is being at the beginning of a system being born as opposed to going to work at an organization that already had created the system. That part has been really, really exciting.

From a learning standpoint — and I’ll just speak from an IT perspective right now — it’s how you merge the cultures of the different organizations, both from a leadership perspective and staff perspective. We haven’t merged all four hospitals’ IT under IS from a cost center perspective, but I am the system CIO over those organizations. 

I work very hard to get our leadership within IS to work with their leadership in their organizations and staff-to-staff communication as well. We’re geographically disparate from each other, so it makes it a little bit more difficult. That part has gone really well. That’s been the biggest thing that we’ve done.

We created an IT council that’s a high-level group of the high-level IT folks. Then we did a sub-group that’s made up of low-level managers but also some staff that are working together across the system and looking at things like linking email and some of the nuts and bolts things that need to be done behind the scenes. 

That’s brought these teams together, working on the same projects. What we’re finding is that the more and more that you do that, it’s going to make it easier as we get to the more difficult projects of implementing different types of technologies in these organizations.

Every hospital has the challenge of trying to look at new tools to support risk-sharing arrangements and population health management, but you’re also faced with trying to combined the financials to give a view that makes sense and to understand the physician relationships.

Absolutely. If you look at the last time we talked in July 2009, we were Fletcher Allen Health Care academic medical center, Burlington, Vermont. Now we’re a four-hospital system. We also are 50 percent owner of OneCare, which is a Medicare Shared Savings Program with Dartmouth-Hitchcock. There’s 14 hospitals involved in basically the entire state of Vermont, about 50,000 covered lives that are under that right now. A very large Medicare Shared Savings.

We’ve got the issues around exactly what you mentioned — the data analytics, advanced population analytics that we’re implementing. We’ve got some unique stuff going on there, along with working with two health information exchanges, because we are not only in Vermont, we’re also in northern New York. We work closely with VITL in Vermont and Hixny in northern New York. They’re working together to link their two HIEs together to benefit us as well.

On the advanced population analytics side, we’ve joined a group called Northern New England Accountable Care Collaborative. That’s made of Eastern Maine, Maine, Dartmouth-Hitchcock, and now ourselves. It’s a unique opportunity. They take our CMS claims data in and using VITL, we move our EHR data into that data warehouse. We can also have access to the de-identified data of the other organizations. Instead of just looking at populations of 300,000 or 600,000, now we can look at populations that are in the millions. The bigger the denominator, the better off you’re going to be.


People claim that healthcare is behind technologically, but we have business models that seem to change every five years, government involvement and reporting, and insurance company requirements. Everybody wants something different on the back end and yet you’re trying to keep the front end running. Is that sustainable? I can’t think of any other industry where there’s so much change that isn’t to support the business, but to meet new minimum external requirements.

I think over the next year we’re going to find out whether this is sustainable or not. If you look at the priorities that we have right now, we have ICD-10 coming. We’ve got Meaningful Use Stage 2, then Stage 3. Privacy and security is huge with the passage of the final Omnibus Rule and we’ve got to spend a lot of time there. We’ve got our system IT priorities that we need to put in place, and then also our OneCare ACO IT priorities that need to be put in place.

You add all those up and just look at the care and feeding of an Epic EHR and the priorities that go into that, it’s daunting. I joke a little with my senior leader that in the past, we were able to do a business planning session, have the IT strategy follow the business plan, and do a three- to five-year IT strategic plan. That’s no longer the case. I can’t even do a six-month strategic plan. 

What I’m trying to get my organization to do is to talk a lot about how do you survive, how do you manage, how do you lead in an organization that every single priority is a high priority? In the past, you could make a list and start at one and go to 10. You might have four or five projects that are twos. But in this particular case, they’re all ones. The federal government deadlines on a lot of these things are all coming to a head. 

How do you get your organization to work in that type of environment? That’s been amazing from a cultural standpoint. What you’re going to see across the country is some organizations will be nimble enough to do that and then others won’t.


Given the low likelihood of success and the fact that CIOs aren’t typically given extra resources, will it be harder for CIOs to keep their jobs?

Absolutely. If they don’t set the expectations with their senior leader colleagues …  even though I mentioned earlier that I make a joke about not being able to do a six-month strategic plan, I’m actually pretty serious about that. If my senior leader colleagues — my boss, my CEO, the board – are expecting a three-year plan and I’m not clear on what our priorities are, even over the next couple of months, and to get them to understand, then I’m setting myself up for failure. I know that has happened to other CIOs across the country. 

This coming year, year and a half, I think there’s a lot of CEOs out there that expect all this stuff to get done. If the CIO is not clear with the individual that they report to, that based on the resources that they have, these are the things that we can get done and these are the things that we can’t get done. We’re also in a situation where you can’t add any more resources. I can’t go to my boss and say, give me 10 more FTEs and I can do 10 more things. It’s just unsustainable from that standpoint. 

It will be interesting. I think there will be a lot of turnover in the next year to 18 months or so as the Medicare penalties kick in as well in 2015. There will be a lot of CIO turnover, I believe.


In the past, that type of environment is where health systems start thinking about outsourcing their IT departments because consulting firms claim they can do more with the same resources and still make a profit. Do you think the environment is going to swing back what seemed to be a diminishing trend of health systems looking outside to have their IT run by someone else?

Yes. What you’re going to see first, though, is just from the healthcare industry in general, the mergers and acquisitions that are happening. I firmly believe that within the next five years, there’s probably going to be 100 to 200 health systems in the United States. They will be regionally focused. Bigger is going to be better in this new world of population health management. That’s happening all over the United States. 

What you’ll see first is merging the IT shops. How that all shakes out will take a little bit of time and outsourcing may play a role in that. But I see those IS organizations working hard to come together first. They may look at outsourcing, but I just don’t think that’s going to be as high a priority as merging these various organizations.


What types of health IT-related businesses do you think will benefit from that consolidation scenario and which ones do you think will suffer from it?

The call center can be outsourced and consolidated probably fairly easily. We’re doing that now across our system. That’s probably one of the easier ones. If you look at field service, network, server management, and data centers, for example, there’s a lot of savings there. Looking at how you merge your data centers and cut some costs there. That’s the easy part.

The harder part is on the application side. If you’ve got more than one Epic organization coming together … you’ve seen one Epic organization, you’ve seen one Epic organization. They all have their different nuances. But most of the systems are coming together. You have an Epic organization and the other one might be a Cerner, and you’ve got to go through a process of, are you going to keep them that way, or are you going to put Cerner in the other organization, or are you going to choose Epic? 

That is going to be much more difficult to do. The application people that support those applications, the retraining associated with that, is just going to be really, really difficult to do and very costly. For these large organizations coming together, you’re talking hundreds of millions of dollars. You’re seeing it now — some of the bigger organizations are doing implementations and mergers and acquisitions at the same time.


There was a lot of buzz recently about your health system announcing plans that it expected to lose a lot of money but also that it would be doing a lot of hiring to support Epic. Internally, is Epic providing the expected benefits and return on investment, or are executives privately questioning whether the cost was worth it?


If you had asked that question a year ago … to be honest with you, I was questioning it. A lot of that was self-inflicted. It didn’t have to do with Epic. We had implemented Epic. We had gone live. We spent a lot of time on the ambulatory side and really got that humming. 

Then we didn’t take care of the inpatient side of things. The inpatient side got very stale. It got very customized. I think we had 70 different flowsheets across the organization. Data wasn’t landing in the database where it should be to get reports out. We ran into that with Meaningful Use. It was very difficult for us.

About a year and a half ago, I hired a CMIO. He came in and one of the ideas he had was that we needed to go to 2012 upgrade. He said, why don’t we just take all 7,000 enhancements and go back to model as close as we can? Originally when we thought about that, we were like, what are you, crazy? Typically when you do an Epic upgrade, you look at 50, maybe 100 enhancements. You never get to all the enhancements from an Epic upgrade typically. 

This was a radical change from that. When we approached Epic, they were really noncommittal on whether we should do that. But the more we talked about it, they gave us the green light. Last spring, we started that process. We went live in October. It completely changed. It was a non-event over a weekend. The training wasn’t too difficult. It became a better system.

Now we’re relying on Epic to do the R&D instead of us building things that Epic’s already building in future releases. We found ourselves doing that when we looked at 2012. We were building things in 2010 that already existed in 2012. It just didn’t make any sense at all.

We got creative on the how we used consultants during that period. We needed some help and we used some firms come in and help us from a resource perspective, because you imagine a whole change going from an 80-20 customized system to more of an 80-20 in the opposite direction model versus a custom system. The changes that we needed to make were huge. 

We worked with a national company, but their local headquarters are here in Vermont. It’s a perfect marriage. They were Allscripts at the time. Their name is MBA HealthGroup. They were nervous based on where Allscripts was going and we needed help, so they came forward. We started talking about us sponsoring them with Epic so that they could create an Epic practice. In return, they would send people, get them certified, and bring them on site at a very reduced rate, about a 50 percent reduction in what you normally would pay. 

After a six-month period, we would have the right to hire, which we thought was great. We view that as a creative win-win situation with them. They’re offering it across the country now to certain organizations. We used them for our training in the Epic space. We hired two of the individuals at the end of the project. We were able to pick the best and brightest out of the group and hire them. That was a win all the way around.

We’re also reaching out to the local colleges and universities here and getting lists of engineering, math, and science majors with 3.5 and above and encouraging them to apply for open positions. We’ve hired a couple of kids right out of college. They have been amazing. The productivity is just … they learn so fast. What we’ve found is you can’t give them a deadline, because if you do, they’ll wait up until the last minute and then get it done. They can do it a lot faster than the deadline that you give them. Just give them the work and don’t give them a deadline and you’ll get much more out of them. That’s been fantastic and we’re continuing that type of program as well.


What are your biggest challenges and opportunities over the next one to two years?

Looking at the next year,we’ve got ICD-10. We’ve got Meaningful Use Stage 2. Privacy and security, which is constant vigilance on that.

Every time you turn around, you see another breach. Everybody’s going to have a breach at some point. At some point, somebody’s going to do something stupid and it won’t be malicious and you’re going to have a breach. But the ones that I see that could be avoided, those are the ones that really get me going. The non-encryption of a mobile device. It makes no sense to me as to why people haven’t done that.

The breaches that are happening, those are the only ones we know about. There’s so many out there that we don’t know about. It’s going to be more and more difficult because OCR is certainly going to ramp up the audits and the fines are going to start coming out. That’s a big one. 

Then the accountable care IT infrastructure that we’re building with the health information exchange and population analytics. Then trying to look at synergies across our system from an IT perspective and where we can save some money and increase services across the four hospitals. My expectation is that the next time we talk, we’ll be larger than a four-hospital system. 

All that stuff has to get done in the next 12 months. Otherwise we’ll be behind the curve on what we need to get done. A lot of other organizations are in the same situation whether they realize it or not. They have these same priorities, especially if they have an ACO or are part of an ACO. Whether they realize it or not, all that stuff is coming to a head over the next 12 months.


Do you have any final thoughts?

I can’t say enough about the privacy and security side of it. A lot of the technology that we use today enables physicians and nurses and clinicians to take care of patients. These systems are helping to give us higher quality, eliminate errors, and impact patient safety. That’s been great and it’s been worthwhile.

But we have a mission — we should have a mission — to protect the privacy of the information within these electronic health records. I can’t go to a bedside and take care of a patient directly, but I can certainly involve myself directly in the privacy and security programs of this organization. I think more and more CIOs that do that and get directly involved in the privacy and security, understand it, make sure you have a chief information security officer, get the tools that you need, figure out a way to justify those, and get those in. For our patients, that’s the one thing that a CIO can directly impact.

HIStalk Interviews Joseph Mayer, MD, CEO, Cureatr

January 6, 2014 Interviews 2 Comments

Joseph Mayer, MD is founder and CEO of Cureatr.

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Tell me about yourself and the company.

I started Cureatr when I was a resident at Mount Sinai here in New York City. Prior to that and during my residency, I’ve always been a clinical research guy. I did med school at Columbia and focused on clinical operational workflow research. How you optimize consults, communication between the floors and pharmacy, and even looked at inter-organizational workflows like PCP into the hospital, etc. This is an area I’ve been passionate about since I started my training. 

I started Cureatr with a guy that I had gone Stanford undergrad with, Alex Khomenko, about two weeks before I started my residency. I had formed this idea during the last couple of years of medical school and worked closely with Bob Sideli at Columbia. I got together with Alex who, at that time was director of engineering at 23andMe on the West Coast, flew out and met with him, and said, “I’ve got this idea. I’m starting my residency in a couple of weeks, but let’s work on this together. I’ll be in a great environment to get feedback to understand what our users need, also what the administrators need.”

One thing led to another. We built out Cureatr  during the first year of my clinical training. Our first real launch was in the medicine department at Mount Sinai in January 2012. 

It’s been really a whirlwind since then. We were part of this New York Digital Health Accelerator program, with 20 leading payor-provider orgs in the state which works closely with companies like ours to make sure there’s a product fit for what their needs are. We just closed our Series A financing with Cardinal Partners and Milestone Venture Partners. It was a $5.7 million around in October of this year.


Many companies are suddenly offering secure messaging for clinicians. Who are your biggest competitors and how is your product different?

We’re running into the guys you would expect, the TigerTexts of the world on the lightweight messaging side of things and on the nurse-first device side of things, Voalte and the legacy guys like Vocera and Avaya.

When I started Cureatr, I was interested in messaging as a part of some of these workflow problems. If you look at what a workflow consists of, you’ve got the communication piece. That’s a huge part of it, probably about a third of your time. You’ve got the documentation piece and CPOE documentation — that’s probably another third of your time.The last third is management, getting access to actual data. Obviously, unfortunately, you probably spend less time on implementation than you do in a lot of other areas of the care process. When I started Cureatr, I was interested in how do we build a tool for the whole part of this. 

Let’s start with messaging. There probably are a lot of messaging companies, but the penetration of these types of modern communication and workflow tools is incredibly low in this market. There’s no clear leader. It’s still a very green market.

We’re trying to differentiate ourselves by coming at this from the angle of, let’s find a couple of specific use cases or workflows that are highly repeated in your organization or for your patient population. Let’s deploy this combination of communication plus some task management plus some basic integration with other systems. Routing and care team mapping is a big part of that. That’s our differentiator. That’s the way we’re looking at helping our customers. 

The other big thing is more and more of our customers are interested in inter-organizational use cases. They need to think about what goes on beyond the four walls of the hospital, because from their perspective, the care episode no longer ends with discharge. We’ve gotten some early customers, like the DaVitas of the world, who are thinking a little bit ahead of the curve on cross-continuum care management and want to apply our tools to those areas. We are focusing on customers who are interested in that today because we think that’s going to be a growing need in the future where we can build some expertise.


Is the model that an enterprise would pay for the system, but there’s an individual app that people can download for free?

We are very hands on around implementation, very hands on around working closely with the enterprise and finding these specific use cases. But we get contacted all the time by folks like my father, a small private practice who want to use it. We obviously see value in letting them, but above value to them, the value to the bigger hospital customers we work with making the onboarding experience for the smaller organizations very easy, very lightweight. But our customers are mostly large enterprise guys like Sinai.


It’s same product that could be downloaded for free, just with more enterprise-type services bundled?

It’s modular. We have our core messaging piece. Then we have something we call structured messaging, which is a feature that the enterprise needs to create a step-by-step workflow for a specific use case. There’s a core, very lightweight messaging piece that’s very easy to download and get up and running within a couple of seconds, but if you want to get those other modules, if you want to get single sign-on, if you want to get documentation or tie in to your ADT or EMR or lab system, that’s what our enterprise customers will get.


What kind of numbers do you have using just the standalone free version versus those that are using it via enterprise?

It’s almost all enterprise customers. We wanted to get the product right. We wanted to build the infrastructure of a company before we started doing a lot of marketing. We haven’t done a lot of this “are your docs texting?” replacement-type marketing. We’ve mostly focused on talking to thought leaders and rolling it out to larger enterprises. I would say 90 percent of our customers are through an enterprise customer, any organization that’s purchased 500-plus licenses.


How many organizations do you have as customers?

We have about 10 large enterprise customers and then some large primary care groups, some larger multi-site practice groups. But in terms of large paying enterprise customers, we have about 10.


You offer read receipts and the ability to attached a photo securely. Is that unusual?

That stuff’s great and useful, but it’s what our customers expect. I would think anybody who is a serious company in the states does have that type of functionality.

The things that are really different between us and the product are, first of all, we built this from the ground up in a hospital and a health system. Our products have been optimized for clinical users. We have status and presence, which is a big thing in a clinical space.

The way I look at the world, and I think the way most providers do, is that there are only probably four or five pieces of information at any given time that are actionable and valuable to the care team. We are trying to create a shared view of the patient around this in real time as much as possible for the care team. It’s tying into those other systems and understanding how to smartly separate the signal from the noise around very actionable information is what we’re trying to optimize the product. But also maintaining a very good, solid, secure messaging user experience. 

That’s why things like read receipts, directory integration, scheduling integration, photo sharing, document sharing …  we have the wound care company that’s piloting our product, and it’s revolutionary for them because all of a sudden they can, instead of having to fax the face sheet from the patient when they’re discharged where they’re going to follow up with wound care or with vascular, they can send the PDF or even send a photo of the face sheet and have a very real-time, two-way back and forth to make sure that that patient is getting the right follow-up care. We’re starting from almost ground zero in healthcare, so things like that can have a very large, positive impact on workflow, on efficiency, on provider and patient experience, and satisfaction and experience.


You have data from Mount Sinai that was self-reported from a survey. Do you have any more specific analyses of either outcomes or anything more than just what the users report?

We’ve got a study that just came out that I can share with anybody who’s interested in following up privately, but we don’t have permission yet from this large academic health center to share that data because it’s literally fresh off their presenting at a conference. But we have some very exciting data around time saved, efficiency linked to earlier time of discharge, i.e. length of stay reduction and HCAP impact. We do not have randomized, evidence-based clinical trial data at this point. Very few companies in healthcare IT do.

We have two customers we’re partnering with to run some 12-month longitudinal studies looking at outcomes on specific clinical hospital performance metrics, both on the inpatient and outpatient side.


How did working with an accelerator help the company?

I am very grateful to the NYeC because we got unique exposure to the best hospitals in New York. Even more than that, everybody who was doing this program was very invested in trying to create a new ecosystem around where … Hospitals are just not used to working with startups. As a startup, time is your most valuable resource. Hospitals don’t move quickly. The thing that we got from the accelerator — more than the money and more than the PR — was literally a very accelerated access and  feedback to the C-suite and users.

The big challenge for anybody in healthcare IT today is, how do you think through the ROI story and how to measure the ROI for your product? There are a lot of companies right now in this healthcare IT space sprouting up. The death of many them will be not thinking about that piece, not having access to the right folks in the big health systems and the healthcare world in general to think through that piece.

That’s what we got out of this accelerator much more quickly than we would have from one customer or from going and talking to your friend’s dad who’s some executive at a hospital. We had invested folks giving us that kind of feedback through this program. I would recommend that program for anybody and I would do it again.


Where do you see the company going in the next few years?

There’s real value in secure texting or replacement pager stuff, but we’ve come up with what I think is the most effective, repeatable process for deploying secure messaging leveraging mining of the data for optimizing secure messaging in these larger enterprise customers. The next 12 months is really about what’s coming after messaging. Optimizing the care team mapping side of things, i.e. routing of messages to the right person at the right time, or routing information at the right time beyond messaging, task management.

These are the workflow tools. That’s what customers are telling us that they want. When you look at the most successful implementations of technology in healthcare IT and most successful companies, they’re very much focused on a couple of specific use cases or clinical use cases or workflows where they’re doing that better than anybody else. Our goal is, let’s find those use cases, let’s deploy messaging and these other tools around it, then let’s actually measure an ROI and let’s actually make it very clear for our customers how to achieve that ROI in future implementations. 

Building the product and the implementation and services side of the business to support that is the most critical thing right now, because from a sales side, there’s great demand for this right now. It’s almost a function of keeping up with that demand and making sure that our product is truly adding value to our customers.

HIStalk Interviews Rob Culbert, CEO, Culbert Healthcare Solutions

December 2, 2013 Interviews 2 Comments

Rob Culbert is president and CEO of Culbert Healthcare Solutions of Woburn, MA.

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Tell me about yourself and the company.

I started my career in healthcare IT back in 1986 working for what at the time it was called IDS, which later became IDX Systems and now is part of GE Healthcare. I spent about nine years working for them at a time where they were growing fast and furiously, selling large practice management and managed care solutions to the academic medical centers and large physician groups and medical centers around the country. Then for the last 20 years, I’ve been in the healthcare consulting world, with the last eight being on my own with Culbert Healthcare Solutions. 

My history there has covered the gamut of helping large hospitals, academic medical centers, and physician groups through a wide variety of business challenges ranging from IT to revenue cycle to strategic planning, the whole bit. I cover a wide spectrum of areas and our company does the same. 

We broke our business into two pieces. We have a very strong IT consulting component that helps Epic customers, GE customers, and Allscripts customers. On the management and strategic side, we help customers with developing medical groups, fixing a billing operation, creating an central billing office, and a wide variety of management and interim management type needs as our customers look to do different things.


You are privy to those conversations about what hospitals and IT departments are planning strategically. What are the themes?

In an older time, physicians and hospitals operated very separately. In my old IDX days, it was all about control or a fear of control. They went out of the way to keep systems and knowledge very separate. What’s really great is that it has come full circle. In the world of Meaningful Use, PQRI incentives, and focusing on quality outcomes and taking good care of the patient, you have to be able to work together and share. 

What we have been doing along that line is helping hospitals become better partners with physicians, providing better services, whether it’s IT-specific in terms of an EHR that has clinical integration with the inpatient data, so that a physician is able to look at a complete patient chart instead of having to go to an ambulatory system for their office notes and switch over to a different hospital system to get access to the inpatient data.

A good chunk of what we’ve been helping people with and we see over and over is, there are many, many different ways for hospitals and physicians to join forces, either officially or unofficially through IT management services and sharing of clinical data.


In those relationships that may vary from hospitals buying practices outright, some sort of affiliation agreement, or an ACO model, what technology challenges do you see most often?

It ranges quite a bit, but I think the common one is cost. Everyone is extremely price sensitive, and rightfully so. A hospital traditionally has a larger infrastructure. It’s got its own campus or set of campuses. They’ve got a large volume that they can make their IT dollars work really efficiently.

Now you ask that hospital to serve a three doc-practice that’s affiliated with your hospital that’s 20 miles away, They just don’t share the same cost structure that a hospital does. They can’t just hire IT analysts. On their own, they have to be able to share those kinds of resources. They have all kinds of issues with being isolated and having to deal with networking issues and the basic infrastructure before you can even get near the application. Then on top of that, they don’t have the ability to be close to the campus to get access to a lot of the training that might be traditionally available in a larger environment.

There’s a bunch of challenges around getting those affiliated practices up to speed and comfortable using the technology, no different than someone that’s in a hospital setting. The cost of serving a small group that is way out in an outlying area is very different than what a large group environment in a campus setting would look like. Those sensitivities around how you provide good service at a very, very cost-effective way is the biggest challenge for hospitals and those affiliate physicians working together.


Do you see a lot of practices replacing their systems, either because they affiliate with a hospital and move to theirs or they get disillusioned with the one they have?

I do. Some for the reasons you mentioned, but sometimes it has to do with who they’re aligning with from a health system perspective. We’re starting to see, for example, independent Allscripts customers where one buys the other. Do you keep the two separate systems or do you bring the two systems together? 

It’s the same thing in the Epic environment. Epic is typically in very large health systems. It’s not uncommon for us to see small- to medium-sized practices that are aligned with one health system on an Epic practice that for very good business reasons and strategic reasons, chooses to switch their affiliation to a different health system. The first question that comes up is, how do I get my Epic data from the one Epic system over to the second system? Getting the HR data as well as the registration and billing and practice management data.

They talk about that at some point it’s going to be a replacement market in the EHR world because everybody is getting close to being on at least their initially EHR. Switching alignments and having to switch your systems potentially to fit with those alignments is going to be a big challenge for organizations in the future.


What factors will have the greatest influence on the hospital CIO in the next one to three years?

They’re going to get more involved, if they haven’t already, in the physician side of the business. It’s a very different business from running a hospital. It takes different skill sets to run a very effective professional billing office compared to a hospital billing office. The same with setting up a clinical system — it’s a very different environment.

The old mentality of hospital IT is going to change. You need to be able to factor in a physician’s side to the business that’s a more nimble and more sensitive to the fact that the physician side changes more frequently than the hospital side of the world. You have less control, because you could have a physician group today that is a member of a different competitor and an affiliation is created. All of a sudden they’re now in your network and you have to service them as a good customer. 

That’s going to be a challenge for hospital CIOs — making sure they have that good balance of having physician expertise and hospital IT expertise on staff to be able to meet everyone’s needs.


What are their biggest challenges in getting that job done?

Resources. Money. Probably the biggest challenge is that still today, many of the healthcare organizations have a large mix of IT systems that they’re having to maintain. 

In many cases, they have the same system, say for example a GE or an Epic system, and they may have two instances of the same vendor. Potentially those instances could be on different versions. Being able to manage multiple systems and all the nuances of those systems for the various entities within the hospital CIO’s responsibility is going to be a big challenge.

Second is how a hospital CIO can make effective decisions on consolidating some of those systems so that you aren’t managing 20 systems when you ideally maybe should be managing four or five. What is the migration path that you have to go through when you’re consolidating so many systems to one? There are so many business issues that you have to be sensitive to that, unfortunately, it’s not a simple as, “We’re going to turn this system off tomorrow and turn the new system on.” You have to to be able to interact with the entire operation department to make sure that you’re not creating business problems while you’re making those system changes.


Will maintenance costs with these expensive systems change the way hospitals manage their vendor relationships?

In my IDX days — when IDX was growing by leaps and bounds and was grabbing a lot of market share, particularly in the academic marketplace — once we got to a size where we were considered the leader, similar stories that you see today about Epic and expensive and is it going to make sense came up with us that we had to deal with.

I don’t think that’s totally fair to say the vendor is the sole problem an organization could look at supporting their systems and say it’s expensive. There are many savings to be had any time you switch to a new system that a lot of organizations the first time around in implementation don’t get the opportunity to implement, because they’re so busy trying to get the initial system up and running, which is why you hear so often that organizations go back through with these optimization teams to make sure that they’re getting the benefit that the systems are providing.

We did an ROI study for one of our customers that helped them in the process of earning a Davies award where we were able to show that the Epic system where they had spent somewhere in the range of $150-plus million over a 10-year window, their total cost was going to be $13 million. We were able to demonstrate dollar savings of that minus $13 million over a 10-year period. Then if you look at all the patient safety and patient satisfaction opportunities that the Epic system had the ability to create, there’s a lot of intangibles that, one would argue, the $13 million was a very, very good investment for the organization.


What trends would you advise a CIO not to jump on in the next year or two?

The ACO and the population management area certainly has a lot of buzz. There are a lot of things going on that, in the very near future, will be very important to every hospital’s CIO’s agenda. But I don’t know if right now there’s enough bandwidth, with everything else that they have going on, that you can jump into those systems and be able to do an effective job. 

As the next year or two goes by, that those systems will mature. The vendors will be stronger. They’ll be able to provide more knowledge along with the product. 

That’s an area where, given everything else that they have on their plate, one could argue that they’ve got plenty to keep them busy without having anything for the next couple of years.


Do you have any final thoughts?

It’s a very interesting time. Our customers are doing a lot of great things, but they’re struggling with too many big things at one time, whether it’s ICD-10 or Meaningful Use. We talked about where, if they’re trying to consolidate systems, the amount of work that they need to do to upgrade to a new version before they could get access to the ICD-10 technology is definitely creating a lot of angst in the marketplace.

The typical hospital CIO and the IT department have got more than their hands full. It’s a very crazy, hectic time. I view our job as to try to alleviate some of that stress, but I don’t know if there’s really any way to do it other than to plug ahead and do a great job with the projects that they’re working on. Eventually, we’ll be able to catch up to the point where they can have a little more control over the priorities that can really make a difference for the organization.

HIStalk Interviews David Chou, CIO, University of Mississippi Medical Center

November 25, 2013 Interviews 5 Comments

David Chou is CIO of University of Mississippi Medical Center of Jackson, MS.

11-25-2013 9-34-39 AM

Tell me about yourself and the medical center.

University of Mississippi Medical Center is an academic medical center. We’re here supporting our research sector, our hospital sector – healthcare, and the medical school. We’re the state’s only Level I Trauma Center and the state’s only children’s hospital. Given that, we are also a state entity, so we are here to provide outstanding care for the state of Mississippi.

I’ve been on the ground here for about almost two months now. I previously came from Cleveland Clinic. I was overseas in Abu Dhabi working on the joint venture project that they had with the government of Abu Dhabi. I was there for almost two years before leaving to come back to the states. I’m originally from southern California in Los Angeles, so I’m accustomed to being in a big city throughout my life until now where I’m in Jackson, Mississippi. Overall it’s going well.


What are your biggest projects and your biggest challenges?

The biggest one now is that we’re looking at optimization. We went live with Epic about 16-17 months ago with a big bang installation. All the hospitals and all the clinics, so campus-wide we rolled out Epic, which is a very great task that was undertaken. Now we’re looking at ways to optimize it.and utilize the system to our advantage. I’ll say that’s probably the number one thing for me right now.


What are your goals for the system and what do you hope to accomplish using Epic?

I would say just utilizing the system to its fullest capability. Right now, we’re utilizing probably about 40-45 percent of the system’s functionality. I want to get it to at least 85-90 percent. In addition to that, some of the main technology initiatives are moving toward the BYOB environment and we’re moving toward virtual desktops. We’re going mobile. I want to get us where we’re one of the very few healthcare players that’s able to support a mobile environment. I want to get away from the traditional client-server setup.


What do you need in terms of infrastructure to support a mobile workforce?

We currently have Citrix as a main partner in terms of supporting Epic. We’re almost there, we’re pretty far ahead. In terms of infrastructure, we just need to take a look at some of the hardware upgrades, then we should be ready. We rolled out Citrix for all of our clients. Everything’s running through our Citrix client. What that means is that we just have to get some of the other healthcare applications to work well with our Cisco container and we should be good to go. We’re very close, closer to what I originally imagined coming on board.


Are other clinicians other than physicians going mobile as well?

Primarily physicians, medical staff and nurses. We have a really big telehealth program here. We have over 85 hospitals on site that are utilizing our telehealth program. Our goal is to get it to over 100+ sites and capture not just the state of Mississippi, but we want to capture the southeastern region of the US and potentially go global. They’re going to be a big player in terms of utilizing the mobile platform.


What’s the vision for global telehealth?

We grew so fast here, in terms of this telehealth program. I think the vision is to be able to provide care for the state of Mississippi and the rural areas first. We want to scale it to where obviously just to be able to service the area of Mississippi, but I think we have the potential to expand it globally. We need to be able to showcase and show everyone what we’re doing here in Mississippi from a telehealth perspective.

It is fast-evolving technology that right now is still very premature, so we’re scrambling at this point. But hopefully we’ll get to stage to where we’re solid and we have a few solid partners that are working with us. Then I think we’ll be able to extend it globally, working with some of the other countries that are in need of telemedicine. You know, given the fact that I was in Abu Dhabi, I see a strong need for healthcare players in North America to boost healthcare globally throughout the world.


Are there specific services that you plan to use in your own institution?

I would say anything. I don’t think the organization has thought about expanding globally, but that’s the sort of the goal that I have in place of the organization, along with my director of telehealth.


Are you doing anything else that you would consider innovative or unusual?

Telehealth and getting solid on a more mobile strategy. Those are the two primary things I would say that’s very innovative right now. We’re still trying to get some of the basics in terms of the basic functionalities in place, but from a healthcare perspective, I would say those are the two biggest areas. From a medical college standpoint, there are a lot of things we want to do as far as mobile strategy as well, but that’s something that’s still a work in progress.


You were a hospital analyst 10 years ago and now you’re the CIO of a large health system. What advice would you give people who are interested in a similar career path?

It’s very important to understand the business side of healthcare. I was fortunate enough to where I was able to roam and understand the various departments. I’ve had various departments report up to me as well, such as supply chain. I have a lot of knowledge from a revenue cycle standpoint. 

I would say really get involved and understand operations, how things work. That’s going to carry a lot of weight in terms of fitting technology into the business side. After all, business drives technology, so it’s very important and very valuable for someone to actually understand how to operationalize the hospital and how to make it profitable.


In terms of educational background as well as experience, what do you think would be ideal for today’s CIO role?

A technology background would be ideal, just to understand how things work and have that foundation. But ideally, someone with a business background, specifically in the healthcare sector. If there’s a passion for that individual on the technology side, that’s a plus, primarily having to be a little more business savvy. Most of the CIOs today have been in technology for a long time and they understand technology, but when you ask them to transfer that knowledge from a technology terms to business terms, there has been a challenge.


How is your relationship with your CFO and how can CIOs improve that relationship?

What’s helped me is the fact that I work closely with my CFO as a partner. He trusts me to help him solve things that are going wrong on the revenue side because I have that knowledge from a business side as far as how to run a business office. That’s helped me tremendously in that relationship to where I’m viewed as a solid partner, not just a technology advisor. I’m there helping from a financial perspective as well. That’s what’s very critical, and that’s what’s lacking these days.


Is the industry is doing a good job of preparing the next generation of IT leadership?

No, I don’t think so. I was very fortunate that at my previous organization, AHMC Healthcare, I was very close to the chairman of the board. I had his trust and he allowed me  roam and take note of the various stakeholders from a business perspective. That was how I was able to understand how healthcare operates from an operational perspective. Without that experience, I don’t think I would be where I am now. I would say that in general we do not do a good job of educating technology leaders on the business side to groom them for the next level.


Your background illustrates that sometimes you have to take jobs that are either geographically unusual or maybe not even desirable jobs to be able to move up. It’s not likely that you’ll just stay in one place and 20 years later you’ll suddenly be promoted. Do people understand that you can’t just stay put and work your way up to the one and only CIO job?

You have a point. You do have to navigate and move around a lot, just to be able to get where you want to be from a career path. Obviously you’d like to stay in one place, but there’s only one role. The chance of someone younger getting that high-profile role is a little bit tougher unless you move around and get some exposure outside the one organization.

I think you brought up a really good point as far as being able to grab on to an opportunity and take the challenge. Once folks get comfortable, it’s hard to get them out of that comfort zone. That’s a big separation divider between someone being able to lead and take on the next role.


Do you think a lot about government decisions about healthcare IT?

I do. I try to stay involved, but that piece is a little bit tougher. But given that we’re a state entity now, I am a little bit more involved than I have been in the past. I did come up from a for-profit institution as well. Now that we’re a state entity, I am heavily involved with the regulatory that goes around in healthcare IT.


Are there lessons you learned on the for-profit side that you can bring to your current employer?

Oh, yes. That was a big separation divider, given that I have a good background in terms of maximizing return on investment and being able to be profitable for an organization. That’s helped coming to this sector, where traditionally from a non-profit, academic standpoint, that has not been the key driver. As healthcare is consolidating, everyone is looking at ways to maximize their return on investment.


You weren’t there when the Epic decision was made, but what return on investment assumptions were built in? What are you measuring and expecting?

Going Epic is the right path. Every healthcare system in the US is trying to get to that consolidated platform. I think they made the right choice. The main drive, the key metric to measure, is how do we look from a revenue standpoint after go-live versus before go-live? I think we’re at the point where we’re above where we were before in terms from a revenue standpoint, but we’re still pretty far from where we can be. We’re looking at a lot of ways to optimize and be that far ahead in terms of from a revenue standpoint.


Do you think Epic will provide a positive return on investment?

We will. We’re utilizing Epic for almost every module. I think we will see a positive return.


People are always asking me what kind of healthcare IT company they should start. What would you say to somebody who’s contemplating that and wonders where the opportunities might be?

The best opportunity is to be a partner and a problem solver. Obviously if they’re not able to solve complex problems, then that niche is not there. Understand the various problems that facilities and healthcare facilities are facing these days and try to find a niche as far as where they can fit in. It’s very easy for someone to be a generalist, but I think focus on a specific area, a few specific niches. That’s where they would stand out.

A perfect example that came to my mind is I worked with a consultant that knew how to help a healthcare facility qualify for and maximize their DSH, Disproportionate Share Hospital, reimbursement. That’s a niche market. There aren’t too many people that can go into successfully and help a non-DSH hospital become qualified for DSH. These are special sort of niches that are valuable. Otherwise, it’s very hard for a small firm that is more of a generalist to be successful in the long run.

HIStalk Interviews Todd Plesko, CEO, Extension Healthcare

November 21, 2013 Interviews No Comments

Todd Plesko is CEO of Extension Healthcare of Fort Wayne, IN.

11-21-2013 9-20-08 AM

Tell me about yourself and the company.

My career began in the ambulatory space in the mid-90s. It was a very interesting time where CMS, Medicare, Medicaid, etc. had mandated that ambulatory care move from paper-based billing and scheduling, primarily billing, to electronic billing. That created a huge boom right around 1996 in the first wave of HIPAA for every ambulatory practice in the country to switch to an electronic practice management system. Then as we know, EMRs came 10 years later, with Meaningful Use and the Recovery Act.

Extension Healthcare is my third startup. We’re well past the startup stage now. We focus on acute care. At Extension Healthcare, we believe fully that the enemy is alarm fatigue.We believe that that enemy will be beat over the next 770-plus days as the Joint Commission focuses on solving that problem via their National Patient Safety Goal on alarm safety.

Today we’re just under 200 hospital clients. Right around 90 staff and four registered nurses. We’re poised to grow very, very quickly as the problem of alarm safety and alarm fatigue in particular becomes more and more relevant, becomes more and more of a discussion point, and of course with the Joint Commission focusing on eradicating this problem, or helping to solve it, with a National Patient Safety Goal on alarm safety.


The ECRI Institute also recently named alarm safety as its number one technology hazard. With all that attention, what’s been the response from the monitor manufacturers, the companies like yours, and the hospitals themselves?

There are only a handful companies that can solve the problem of alarm fatigue. In fact, that’s a very small amount. What’s important for your readers to understand is there’s a very distinct difference between an alarm and an alert. There are many companies out there focused on alerting, which is low priority — something that may not be clinical in nature and doesn’t require a response to that event. Alarming is very, very different. 

As it relates to the monitor manufacturers, some of the EHRs and other companies that are just on the outside or adjacent to the middleware space – which is a word traditionally used to describe what we do — we see some of them entering the market. But most of them are leveraging tried and true companies, like Extension Healthcare, to deliver those alarms and alerts and allow a knowledge worker — a nurse or a physician or someone else in the hospital clinical — to respond to those alerts. Event response is a very, very important topic for us. It’s something that’s not talked about a lot. But in our view, it’s at least as important as delivering an alert with context to the caregiver.

Most of the companies understand that middleware, alarm safety, alarm management, and event response is a business all its own. It’s taken us years and many, many millions of research and development dollars to get to the place where we support every major device on the market, every EMR on the market. Every input that you can imagine, we support. Every output you can imagine, we support as well, which is equally important.

As the world moves towards smartphones, specifically iOS and Android, what people often overlook is that the majority of devices in place at a hospital today continue to be voice over IP devices. We believe that the only way to effectively begin to solve the alarm fatigue problem is to recognize that most communication begins with an event, an alarm or an alert; recognize the fundamental difference between an alarm and an alert; be able to support hybrid environments from pagers to voice over IP phones to smartphones; and be able to work inside the four walls of the hospitals and outside as more and more workers begin to work outside of the hospital.

Those several statements alone are enough to deter a lot of would-be companies from entering the space because it’s just a daunting challenge, not to mention the regulatory environment. We are a Class II regulated medical device focusing on alarm safety in the alarm safety category. That’s a daunting challenge for any company and something that obviously we take very, very seriously.


Just to put the market in perspective, who are your top two competitors?

I don’t consider any company in the space to be competitors with what we do because we go about it a different way. In the traditional middleware space, Emergin and Connexall are probably our top two competitors. Two companies that I have a lot of respect for.

Emergin created the industry. They changed dramatically when Philips bought them. We have many, many — upwards of 20 — ex-Emergin staff with us now, something that I’m proud of. They bring with them tremendous knowledge.

The way we handle data is very, very different from anyone else on the market. We believe that context is king. Context means everything when it comes to solving the problem of alarm fatigue, truly solving it. 

The two companies I mentioned, I would consider first generation middleware companies. We consider ourselves the next generation of alarm safety and event response companies because of the way we handle data, because of inside the four walls, outside the four walls, and most importantly, because of the way we enable event response. That’s very, very important.

I had mentioned earlier that the most important thing, we believe, to solving the problem of alarm fatigue is delivering context with an alert.  We’re running a clinical study now where we’ll soon share with the community exactly what that number is — what percentage of clinical communication begins with some event, an alarm or an alert. We believe it’s very, very high. Soon we’ll have those data.

If you believe that, and you believe that context is king as we do, that means that the only way to truly solve the problem of alarm fatigue is to deliver the five Ws — the who, what, why, where, when — in the form of an alarm or an alert to the appropriate caregiver at the right time on the right device, whether that’s a smartphone or a voice over IP phone, and whether it’s inside the four walls or outside the four walls. Then the event response piece occurs. That event response today is predominantly secure text messaging. 

Those are the full components required to solve the problem of alarm fatigue. If you don’t have context, you are sending an unintelligent alert. If you are not sending the who, what, why, where, when, the user has to ask those questions. That’s just yet another interruption that contributes to the problem of alarm fatigue. That’s why we believe that those first generation companies or competitors are missing the boat on actually solving the problem. Evidence exists over the last five years that hospitals that have installed first generation alarm safety middleware have indeed contributed to the problem and not solved it. 

We’re taking a very, very different approach, which includes delivering context inside the four walls and outside and allowing event response via the form of voice or secure text messaging – point-to-point, point-to-group, etc., to truly finally solve that problem. It’s killing people, it’s costing a lot of money, and it’s a big dissatisfier for nurses and for physicians. 

We believe over the next 778 days, the time between now and the Joint Commission mandate, that the problem can mostly be solved by intelligent, contextual systems that allow for event response.


A lot of the work with alarm management seems mostly to be routing and prioritizing an excessive number of alarms or notifications that weren’t significant to begin with. Can monitors be made smarter so that they do more than just display information and make noise all the time?

That’s what our system does and that’s what other systems do. It’s not just our system that can solve that problem. To take data in, parse out what’s relevant and what’s not relevant, determine what’s actionable and what’s not actionable. That’s really a small sliver of the problem.

Imagine stripping out some of the data that the alarm is sending, the physiological monitor in this case. Stripping out what’s relevant and what’s not relevant, packaging what’s relevant with the other who, what, why, where, when. Typically that’s not coming from the monitor. That’s going to come from the EHR and from other systems like nurse call systems. Often the “who” comes from there.

That’s going to, in delivering an intelligent alert, someone who can be actionable with it. What happens today is a lot of those alerts go to someone who’s on break. The system is not intelligent enough to understand presence and whether someone is actually available, or whether that person can actually solve the problem or act on it. We don’t see the monitors doing that any time soon. That’s why we work closely with those companies and we’re proud to do it. That’s precisely the problem we solve. 

Most importantly, it’s just a fraction of the problem is getting that monitor alert to the right person at the right time. That’s a sliver of the problem. The bigger problem is context and how the user will interact with those data, something that we call event response.


Has anybody done statistics on how many of the alerts that go through your system or other systems are found clinically useful by the clinician?

There is a cacophony of bells and whistles going off in a hospital. Walk through one someday and it doesn’t take long to get a headache. You can imagine what those nurses do day in and day out, God bless them.

To my knowledge, the clinical studies, as it relates to alarm safety, are lacking. I’m really glad that you asked this question. One of the things that we’re doing with a new program that we call Extension Evaluate, a free service designed to collect those data for a hospital. Think black box recorder. We put Extension Evaluate in. Because of the way we handle data, it works out of the box. 

As opposed to sending alarms, triggering alarms, and communicating with endpoints, Extension Evaluate sits and listens. It listens for 30 days. And at the end of the 30-day period, our consulting group sits down with the hospital and shows them a very deep and illustrated picture of what’s happening with their alarming and alerting environment. Those data are incredibly valuable, especially spread over time. Nobody to my knowledge ever in the space has collected those data longitudinally over time and reported on them. From an academic, clinical study standpoint, that’s exactly what we intend to do with Extension Evaluate. 

We’re solving two problems. One is allowing hospitals for free, no risk, to get a very good and deep picture of their alarming environment. Then of course a gap analysis between where they are today and what they need to do to be compliant with the new Joint Commission mandate. But also building a compendium; building a library of data that can be used and regressed to answer the question you just asked. To answer how many alarms are actionable. How many alarms beget a clinical communication. We believe that number’s incredibly high.

That’s another clinical study that’s currently underway. If you have to communicate with someone as a nurse or a physician, how often does that begin with an event, an alarm, or an alert? We believe the number is very, very high, well into 80-90 percent. Soon we’ll have that exact number. That’s something that we’re very excited about — contributing to the academic community on true statistics taken from real-life hospitals longitudinally over time.


Nurses are on the hook to not only set up and adjust the monitors, but respond to the messages they issue. Are problems caused by nurses not having the time or knowledge to perform as monitor maintenance techs?

While some of that may be true, we would never, ever blame the nurse. Our view at Extension Healthcare is truly the nurse and the physician are the most important knowledge workers in the country. Nurses in particular have an incredibly challenging job, maybe the most challenging of any job in America. I believe it’s incumbent upon companies like us and the monitoring companies, perhaps biomed and IT, to design clinical workflows that truly contribute to solving the problem.

That is where a lot of the first generation alarm safety middleware companies have not spent enough time – pausing to evaluate what is truly causing the problem and what’s contributing to it. It’s very easy to send out, for instance, a Code Blue alert to a code blue team when someone is in asystole. It’s easy to send that via a phone or a pager or overhead. What’s not easy is to do it in a silent way and allow the first responder to respond in a silent way,and inform everyone else on that team who’s in different areas of the hospital, perhaps even outside the hospital, of exactly what’s going on — the who, what, why, where, when. That is what we call event response and probably the most important thing. 

For me, for us at Extension Healthcare, it’s about educating and informing the nursing community about which workflows make sense and which ones don’t. Because a lot of the time, tried and true methods that are in place today are actually contributing to the problem and not solving the problem of alarm fatigue.


Do you have any final thoughts?

The future is very important. Our space is dynamic. It continues to evolve. Data handling will become more and more contextual. Alarm management systems will continue to become much more advanced in terms of rules engines and complex rules processing. Clinical algorithms will become part of the system. All of this will advance patient safety and complexity even further. 

It’s very, very important to take into account not only where we’re at today in lessons learned from the past, but also where the industry’s going. Not only in terms of which device a nurse will use, but which data to deliver to a nurse or a physician, the context, and how they’ll interact with that. Not only now, but in the future, to drive down this evil, evil problem of alarm fatigue.

An HIT Moment with … Stephane Vigot

November 20, 2013 Interviews No Comments

An HIT Moment with ... is a quick interview with someone we find interesting. Stephane Vigot is CEO of Caristix.


Are HL7 interfaces becoming more important or less important with the push for interoperability and the popularity of integrated hospital systems?

HL7 interfaces are becoming more important than ever. Interoperability matters because information has to flow in order to improve patient outcomes, reduce error, reduce costs, and remove duplicate testing. Despite the popularity of integrated systems, much of the data in hospitals, physician practices, and other organizations is still siloed.

ICD-10 computer-assisted coding systems need interfaces. HIEs rely on interfacing. We can’t address continuum of care and accountable care issues unless disparate systems can share information, which requires interfacing.

The next big leap forward we’re facing in healthcare IT is actually using the data in the systems we’re buying — in other words, analytics. Again, interfacing plays a big enabling role here, and in fact, the lack of easy interfacing is why we’re still early on the hype cycle in clinical analytics.


What’s the hardest part about designing, building, and maintaining interfaces?

Stop me if you’ve heard this before. They say that when you’ve built one interface between two systems, you’ve built… one interface. Marc Probst, CIO at Intermountain Healthcare, did an interview where he said, "I have a huge staff that does interfaces. And every time the software changes, they do interfaces again. And every time we have a problem, they do interfaces again. It’s not efficient."

The hardest part is that the work you put into one interface isn’t reusable,unless you use Caristix software, though I promised Mr. HIStalk I wouldn’t pitch. HL7 messages and interfaces are everywhere — we just don’t see them. A few weeks ago on HIStalk, Ed Marx wrote about how he sends handwritten thank you notes. The people who really deserve them are the analysts, developers, and testers who design, build, and maintain interfaces. When they do their jobs right, no one notices. When something goes wrong with an interface, that’s when the help desk lights up and they get an earful.


People often express frustration with HL7, saying that system vendors use it in ways that are anything but standard. Is that the case?

To be honest, yes. But can you blame vendors? No. The HL7 standard actually lets you customize an awful lot, from the codes used to indicate patient gender — there are six, and providers can change them — to the length of fields, to how you mention a date. There is a big difference between a date expressed as "2013-11-24" versus "November 24, 2013."

A vendor has to make these calls because the standard doesn’t and the standard wasn’t designed to. I don’t blame the standard because there’s no getting around the fact that healthcare data is complex. Think of a barcode transaction at the grocery store. That’s five to 10 data elements. A med pass with barcode verification, easily 1,000 data elements. 


How has your market changed with new Meaningful Use and HIPAA expectations?

Meaningful Use has made some forms of interoperability and information exchange must-dos. The interoperability requirements that were optional in Stage 1 are now core in Stage 2. That places increased pressure on vendor and provider teams to specify, test, and deliver the interfacing-related components of these requirements. The new HIPAA expectations mean that business associates, not just covered entities, need to be more vigilant in preventing theft; loss or improper disposal of data; or direct disclosure of PHI. We’re seeing that it’s becoming increasingly important to be able to show exactly what measures you’ve taken to secure PHI, whether you’re a vendor or a provider.

In the case of HL7 data, if you’re reusing production data in testing systems, you must remove the PHI. We had an example of a vendor customer who worked with months of retrospective HL7 messages from a provider organization. They were analyzing physician performance for a new product, and both organizations were adamant about protecting that PHI.


What are some of the strangest or most interesting interfaces customers have built?

The strangest interfaces? Well, who am I to judge? The most interesting interfaces aren’t about simple data exchange or orders and results. The workflow is transparent and the benefits are immediate. The most interesting ones right now push the envelope on analytics, pulling data that is really tough to get to, and it’s incredibly gratifying to see our software play a role there. I can’t wait to see what our customers come up with next.  

HIStalk Interviews Bruce Springer, CEO, OneHealth Solutions

November 15, 2013 Interviews No Comments

Bruce Springer is president and CEO of OneHealth Solutions of Solana Beach, CA.

11-15-2013 7-34-10 AM

Tell me about yourself and the company.

I’ve been in the healthcare software industry for about 20 years. One of the early companies I started and co-founded was WebMD in 1996 in Atlanta. Since then, I’ve served as a CEO and board member for numerous healthcare technology and startup companies. After serving as a board member for OneHealth last year, I was asked to join as CEO of the company.

The company is a social health platform company that works with health plans, employers, providers, and patients. Typically working with them to help improve health outcomes and lower costs utilizing social media, clinical tools, and gaming to better manage chronic patient populations.


Why is patient engagement such a hot topic all of a sudden?

Partly it’s due to government regulations. You look at Meaningful Use and you look at many of the different QA programs. Patient self-management, self-engagement is becoming a critical component of any one of those programs. As the risk is starting to shift from the insurance company to the employer and now down to the provider, they’re realizing that they can’t manage that care in these high-cost centers in the physician office, the clinics, and then the hospitals. They need a new way to get the patient engaged into reducing their own cost and managing their own conditions. That will greatly improve the outcomes for the whole industry.

But engagement is only a piece of it. In the past, engagement was a call from a nurse in the call center once a month to check in on you, or a direct mail piece to your mailbox. But is that really engagement? If you don’t get them to consistently or persistently engage and create better habits, you’re not going to change behavior. And if you don’t change behavior, you’re not going to really reduce the cost of the system.


There’s a theory that patient engagement increases the involvement of people who are already motivated, but doesn’t do a whole lot for that vast majority who rack up most of the expense. Do you agree with that?

I very much agree with that. One of the approaches that we’ve had at OneHealth is to engage them anonymously. They can join into communities where they don’t feel threatened, or maybe they have a shame-based behavioral mental health condition that they don’t want to share with others. The ability to do that where they’re not known and there’s no fear of retribution, no concern for confidentiality, where they can get in and work on the things that matter most to them, that their employer, their doctor may not even know about. 

We’ve integrated behavioral and mental health-related capabilities with medical conditions to help patients be able to engage where they want to engage, versus many disease management programs where you start at Step 1 and you go through Step 10. Why not engage somebody where they want to engage on the thing that’s most meaningful for them that they want to change? Then if you help them there, you’re going to make a radical difference on their overall health. 

We always look at things like diabetes. Our diabetes community is driven by weight management, depression, other things. It’s not because I’m a diabetic, but 50 percent of diabetics are also depressed. If you don’t deal with those depression-related issues, it’s going to be very hard for you to get somebody to take their meds, adhere to their care plan, lose the weight, and do the work that they need to manage their diabetes. You have to look at the underlying issue and help them support that issue. That’s why you don’t get meaningful engagement across broader populations.


I tried the site this morning and it was really easy and encouraged people to register anonymously if they prefer. I like that users can click their current mood, find cohorts to interact with, and set behavioral goals. What are users finding most valuable of the site’s functions?

Everybody’s different. It depends on where they’re willing to begin their journey. The emotional indexing that you talked about is something we present every time you check in. That is a scale of one to five, how you’re emotionally doing, will potentially create a bad behavior. Then we measure that scale against the communities that you’ve joined to determine the concern or the level of intervention needed to help that member avoid that emotional feeling driving to a bad decision.

For instance, this company was started with alcoholism, managing chronic conditions around substance abuse. Somebody’s craving at that point in time. If you don’t intervene, they’re going to probably drink. It’s allowed the platform to have a 24/7 intervention. When you check in craving, your network, our coaches — we have our own OneHealth coaches — will now engage you at that point, at the very instant where you’re having that emotional feeling, before you actually create a bad behavior that corresponds to it. We get 97 percent utilization of the emotional check-in on a daily basis for those members that check in.

We have challenges that are highly popular. Right now we’re running a nutrition challenge where people are taking pictures of their plates of food at dinner. Our nutritionist will review them and say, here’s things you could have done better, here’s a way to better manage and balance that meal. Then we create teams and they support each other and have a good time.

We just had a stress challenge where you were picking something in your life that causes stress and creating an anchor around it and an intention to solve it. Then every day, we had chat rooms and meditation rooms for folks to come in and just relax for five to 10 minutes during their busy day. Our coaches would give them tips every day, different tip on things that they could be doing in their life to reduce their stress. 

The challenge communities have become a very active component of the program as well as our expert discussions. For each of our communities, we have a physician or psychologist who’s an expert in that field. Weekly, they’re getting on and doing live video chats about new things, content, things that they should be looking for that particular disease or community that they’re in, or the co-morbid things that they’re dealing with. We record every one of those expert discussions and we put them back on a podcast, so if you miss it live, you have the opportunity to come back. As well as our group chats. We have video chat capability for up to 50 individuals at any one time. People participate in our chats and our group programs on a daily basis. 

Just connecting with others, supporting others, finding others in need, and engaging them and helping them through their journey online. That’s the most powerful part of the social community. Are you more willing to talk about your disease or your issue with somebody at your work or somebody in your home who may be a trigger for the reasons why you have those particular issues, or are you more willing to work with somebody who has the exact same issue, has been through the exact same program that you have, and is trying and working towards their own journey for curing or managing that condition, or better yet, a peer who has already achieved it and is helping another peer, help them achieve their own goals? That’s probably the most powerful piece — the social network and the interconnectivity of like users.


Do people interact differently a Facebook-like setting than they would either in a small group meeting or on the phone with a provider?

Very much so. It’s funny because our members say to us, Facebook is the place I go when I want people to believe what I want them to believe. OneHealth is a place I go where I am who I am. I’m not going to put up my mental health, my depression, my stress anxiety disorders on Facebook and let people know that I have it. But on OneHealth is the place I go where I am who I really am and I really am trying to get help for it. 

If you look at most social networks, 98 percent of users on social networks are lurkers. They’re not really the folks that are engaging and driving content. They’re consuming content, reading other people’s stories, reading other people’s pictures. There’s benefit from that in a healthcare setting, because now they’re reading about people who are dealing with the conditions they are. They’re getting educated about it. They may not personally engage.

But once we get them engaged — whether it is getting them to an expert discussion, getting them into a meeting, connecting to one of our health coaches, connecting to their peers — once they start making relationships, our little nudge to get them into the program is they have the ability to empathically respond. On Facebook, you can “like” something. On our site, you can like it, you can understand it, you can say, “I felt like that, too. I’ve been there before.” You can relate to the person just by pulling down and clicking a button, opening somebody up to the discourse with the other members. 

Once they do that, they start getting integrated into the platform. They start getting social. Once they start getting social, then we’ve got the opportunity to create consistent engagement to drive results.


I assume it’s insurance companies and employers that foot the bill. Does providing that peer support pay off for the folks who are paying for it?

It does. We’ve done studies. We did a pilot program with Aetna around acute substance abuse addicts that were high cost, high acuity to their system. We ran a pilot study where we took a cohort and then they took a cohort through their traditional care management process. They attributed us with reducing readmissions by 58 percent and gave us $9,000 in medical savings in the first year. We did a claim run on every one of the members. 

One of the interesting things in that cohort, folks with substance abuse, was we didn’t stop people from relapsing. People still relapsed. These were highly acute substance abuse members. When they did relapse, they came back to OneHealth for support versus going to a clinic, going to a high-cost center. Most of the folks we did keep sustained in their sobriety, but those that did fall off, they came back and used the social support of OneHealth to mitigate the cost of the health system. We have numerous studies like that across different entities.

But to your point, yes, we started with health plans because they have a large population of members that we could provide this out to to be able to get the data so we can provide clinical evidence about our efficacy, our return on investment, which we believe is both medical savings, reduction in medical loss ratios, as well as operational savings. Can we manage a broader percent of the population at a lower cost than using a call center or a direct mail piece? People use us for multiple ways to save dollars, both medical and/or operational savings. 

Once we expanded the platform to include integrated behavioral and medical conditions, we then started working with self-insured, large employers. We started working with Carlson, Safeway, Tyco and others on a direct basis. 

We also have over 30 providers now that are working with us, either because they’re taking risk towards an ACO model and they’re looking at ways to manage populations outside of the acute care setting and integrating behavioral, where they’re traditionally a condition based on a medical condition, integrating the behavioral management component into that process. Those are folks like Memorial Hermann in Texas and Boston Medical Center that are working with us on lots of different programs and lots of different types. We will start putting up some white papers on the results with them fairly shortly.


Do you have any concluding thoughts?

The industry of population health management is obviously growing and it’s got lots of different components. To truly manage these populations that are at risk, we believe the social media component has got a place in that world, especially when you’re looking at it from a peer support model.

You can really drive highly effective engagement. You get people who otherwise wouldn’t engage with the industry to engage. You have the opportunity to do a lot of unique things that are hard to do through a call center or a phone-based service. It has the opportunity to play a significant importance in behavior change, reducing costs, and driving value to the health system.

HIStalk Interviews Terry Edwards, CEO, PerfectServe

November 11, 2013 Interviews No Comments

Terrell “Terry” Edwards is president and CEO of PerfectServe of Knoxville, TN.

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Tell me about yourself and the company.

I started PerfectServe in the late 1990s. Prior to that, I was with a company called Voicetel, which was one of the early pioneers in the interactive voice messaging space. While I was there, I identified needs to improve communications in the healthcare industry, starting with the physician practice. All of our early development was working with physicians and independent practices, group practices around the country. We began to grow the company. 

In 2005, the practice opportunity led into the hospital in the acute care space. We entered that market in 2005 and that’s been driving PerfectServe’s growth ever since. In terms of where we are today, we have 80 hospitals under contract. We’re serving doctors in about 12,000 practices in the country. There are more than 30,000 physicians on the platform today. We’ve had good growth.


In the old days, hospital people would  have a list of pager numbers for doctors or would call their answering service. How has that changed?

There’s more variability today than there was. We’ve got not only pagers, we’ve got secure messaging apps, we’ve got websites where we can go to get messages to people. We still have a plethora of answering services, call centers, and hospital switchboards. It’s all this variability that results in the inefficiency in communications overall, between clinicians especially.


You mobile app does just about everything—doctor-to-doctor calls, calls to patients that mask the originating number, and secure messaging. How are doctors using all those options?

The mobile app for us is just one interface into the platform. It’s designed for the doctors to do a number of different tasks, some of which you mentioned. 

The real core value that PerfectServe provides is enabling more accurate and reliable processes. We’re taking out a lot of the variability, some like we described earlier, and as it relates to different contact methods or different contact modalities. There are also process rules that tend to be based around clinical work groups, whether it be three cardiologists over here or maybe it’s a STEMI team or a stroke team or a group of internal medicine doctors. 

For every one of these little groups of practicing clinicians, there are a host of if-then type rules to determine just whom to get a communication to.  For example, if we need to contact a hospitalist, we may need to know whether this is about a new admission or an established inpatient because the clinician who receives that communication is likely to be different. If it’s an inpatient, it’s which hospitalist is caring for this patient right now at this moment in time. It’s those things that add another layer of complexity. 

PerfectServe’s strength is in building those routing algorithms into software so that we eliminate the need for the initiator to know who to contact. We’ll route the communication automatically to the appropriate provider. That’s how clinicians are using PerfectServe. It’s about connecting with the right person. 

If I’m a doctor, it’s about making sure that I’m getting the calls and messages I’m supposed to receive when I’m supposed to receive them. That mobile app that you see enables me to do some things like change my call schedule, change my contact modality, follow up with a patient, access messages securely, and access colleagues.


You’re saving time and improving efficiency, but what’s the patient benefit or the satisfaction benefit to the clinician?

We’re taking waste out of the communication cycle time. This is important because in every hospital, every day, hundreds — or if it’s a large hospital, thousands — of times a day, nurses and other hospital staff or other clinicians are reaching out to doctors in the course of providing care. Some of them are in the hospital. Many of them are not. Sometimes it’s not just a doctor, it’s another member of the care team, such as a nurse practitioner. 

We’ve done a number of studies — time motion studies, process flows — and PerfectServe has proven to reduce the subsequent or repeat call attempts by 81 percent and cut the nurse-to-physician communication cycle time by more than two-thirds. In fact, we did one study at the Orange Coast Memorial Medical Center in Orange County, California where we took the average nurse-to-physician contact time from 45 minutes down to 14. 

What that means is that clinicians are able to intervene more quickly because these are all care-related communications. They will range everywhere in urgency to “I need you right now, a patient could be coding” to “this is something that’s important, you probably need to know about it by tomorrow morning so you can take action when you come in to round.” These things have an impact on patient care risks in terms of reducing sentinel events and can have an impact on throughput. We’ve had clients measure improvements in ED throughput, impact on length of stay, reduction in code blue events, and many, many areas of hospital operations.


Does your system help close that loop where you page someone, you never get a call back, and the ball gets dropped?

It depends. Oftentimes there may need to be multiple contact methods deployed. Just due to the increased concern around HIPAA, we’ve had a higher adoption of secure messaging as a primary means of contact when a message is involved versus a live phone call. But secure messaging is reliant on our mobile app, which means we’re dependent on the wireless networks, whether it be Wi-Fi or the cellular. While we’ve got much better cellular coverage and Wi-Fi coverage than we had five or 10 years ago, we still have areas where the coverage might be somewhat spotty. 

As we’re working with our clients and our physician end users, we will try to get them to adopt fail-safe processes. In a fail-safe process, we might be notifying one or multiple wireless devices, so we could be sending a push notification out via Apple’s push notification services, for example, but if the message is not retrieved within a certain time period, we might escalate to a pager, which a doctor still may need to carry based on where he or she goes in the course of practicing medicine. That still may be the most reliable device for them.


Most people would say that texting and paging aren’t HIPAA-accepted ways to communicate PHI. Do you think hospitals are worried about that?

There’s a lot of confusion in the market related to HIPAA compliance and secure texting. It stems from not a real good understanding of what the laws say. There’s nothing in HIPAA regulations that says sending a text message is a violation. What the laws say is that you as an organization, as a covered entity, need to conduct a risk assessment. Based on that risk assessment of where PHI is being transmitted and floating around in your organization, you need to establish effective policies and then implement those policies using various tools and technologies. Then monitor your performance over time. 

There’s like this spotlight that’s  being directed towards just text messaging. But when we look at clinical communications, it’s like a floodlight. What we see is that there’s PHI floating in a lot of different places via a lot of different means. That’s the part that I think the industry doesn’t fully understand right now. We’re doing our part to educate people. We’re beginning to see people understand that there’s more to that issue than just texting.


How are you finding the quality of the average hospital’s Wi-Fi?

Because we are able to work with a number of different modalities, we’re device agnostic from that standpoint. But it is interesting. We see a variety of different qualities of Wi-Fi infrastructure and we also hear a variety of different things. Wherein some organizations, the IT group might say that the Wi-Fi network in its organization is really robust, and then you talk to some of the physicians and they’ll tell you exactly the opposite. So it’s kind of spotty. I wouldn’t say universally across the board that the industry has overall a real robust infrastructure. I would still say that it’s fairly spotty and organization dependent.


One of your selling points is you don’t just work within the four walls.

That’s right. PerfectServe is really about improving clinical communication processes. That’s the heart of what we’re about doing.

I talked about getting into the acute care space. The core application that’s driven the growth there is improving the hospital-to-doctor communication process, because it’s one that’s filled with a lot of complexity. As we come into an organization, we’re about enabling the clinical leaders to enact and drive a process change across the entire medical staff. We have the technology to do that, but we also have the implementation services to make sure the technologies are implemented properly. In other words, the algorithms are built based on the workflows of the different groups and the physician preferences. We’re also able to share best practices because we’ve learned so much working with doctors around the country. 

We’ve also have the support services to help them maintain that improvement over time. Our client advisors work with our customers to then build on those improvements. That’s really key, because a lot of the problems that organizations might want to solve — whether it be say around a consult process, critical test results communication, or ED patient notification — many of these problems can’t be fixed because the underlying process infrastructure is broken. When we deploy, we’re coming in and fixing that underlying process. Once you have it fixed and you have everybody on a common platform, you can then build on it, and that’s where the client advisors come in. 

The other piece is that the applications work not only in the acute space, but they work in the pre- and the post-acute space as well. We may have, for example, a group of hospitalists and a group of referring primary care doctors. We’re able to manage communications between the two of them, between the nurses and the hospitalists, among the primary care doctors and their patients, as well as maybe the skilled nursing facilities or the long-term care facilities where those doctors are also seeing patients. It’s just one system that the doctors have to manage the communications that flow from all these different sources. That’s a real strength of the organization. We’re able to do it via platform that enables them to achieve their HIPAA compliance standards as well.


The company’s been around 16 years and you’ve been there the whole time. What are the biggest lessons you’ve learned about building a company?

Oh, gosh, there are a bunch. I think I’m going to write a book one of these days. There really are many. There are lessons from just general things of starting up any kind of business to working with venture capitalists in raising money and the challenges you go through as you take a company through its various stages of growth. Organizations change significantly when you’re going from $1 million to $5 million in revenue, and then from 5 to 10, and 10 on to 20. The fact that I’ve been able to go through all those various stages has been quite an experience. 

Just selling into hospitals is tough. It takes time to get traction. You’ve got to be persistent. You have to be patient. I love working in healthcare because I enjoy the people. Most of the people that we get to work with — the doctors, the nurses, the executives running hospitals — really want to do the right thing. That’s what we’re here to help them do. But it’s been a lot of fun at the same time.

HIStalk Interviews Pamela Arora, CIO, Children’s Medical Center

November 5, 2013 Interviews No Comments

Pamela Arora is VP/CIO of Children’s Medical Center of Dallas, TX.

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Tell me about yourself and the medical center.

At Children’s, we’ve reached our 100-year anniversary, which certainly shows that Children’s Medical Center here is here to stay. Relative to the organization, we’re a not-for-profit. We’re the fifth-largest pediatric healthcare provider in the country. We have campuses in Dallas, Plano, and Southlake, which is around this Dallas-Fort Worth area. We also have 15 My Children’s pediatric practices. By the end of the year, we’re expecting that to be 17.

From a Children’s standpoint, not only do we have the hospital and the ED and we’re a Level One trauma center, but we’re also affiliated with UT Southwestern Medical Center. We have been working the hospital, the ambulatory setting, with over 50 subspecialties, and we have these primary care offices around the area here.

Relative to my background, I’ve been here at Children’s as CIO for approaching seven years. When I joined Children’s, it was just embarking on its Epic deployment. Prior to that, I was CIO at UMass Memorial in central Massachusetts in Worcester and have over the years worked in information technology — including some of Ross Perot’s companies, Perot Systems and EDS — working in a number of industries, including healthcare.


How is it different working in a children’s hospital instead of a general one?

From an electronic medical records standpoint, we really do have to look at weight-based much more extensively and from the standpoint of how the alerts work. It does have unique aspects that really affect the quality and safety of the children that we serve. 

From a non-EMR standpoint, what I do say, which isn’t so professional, is that grumpy adults lead to grumpy adults, but kids, the pediatrics — they bring out the best in everybody. Really, I find that the folks here just love to adopt technology. It really is about making life better for kids. It helps people focus on, let’s say, the larger end game, just because with these children, they’re just amazing as far as how they’re working through their various conditions.


Someone from outside might say, gosh, you don’t have any Medicare to deal with. 

We have a huge Medicaid base. We do have Medicare as well, but Medicaid is administered at the state level. That’s about 60 percent of our population. Relative to Medicare, we have that as well.


How did you choose Epic it and how do you view that project?

With Children’s, they’ve been a Cerner shop as far as hospital-based. We still have a footprint of Cerner within our back yard. But we’re for the most part Epic in a single instance. That has ended up being a good solution for us and we have a very strong ROI for our deployment.

Why switch from one EMR vendor to another? As context, our ambulatory clinics and our primary care office — at the time there was one – were on paper. When the organization was going to deploy an enterprise solution, a single instance across the entire organization, we stepped back, looked at it strategically, also took a look at our campus partners with UT Southwestern because we’re a teaching hospital and we certainly collaborate very well with Parkland, who’s also on this campus. 

A strategic choice was made to go to Epic because our partners on the campus were also going to Epic. When you think of physicians that work in multiple environments, residents that may be working in Children’s as well as over at Parkland or one of the two hospitals with UT Southwestern, being able to be on the same EMR helps the care delivery.

In addition, our patients flow among the campuses. A baby might be born in Parkland and then end up being here at Children’s because they have broader needs. Sometimes from an ancillary standpoint we deliver services across the campus. Being on the same electronic medical record really helps.

We took it beyond that. We had cross-campus standards groups that clinicians engaged in to help us standardize how we deployed these three separate instances of Epic across our campus partner organization.


I’ve never heard of anybody collaborating with what could be considered your competitors. It’s interesting that for the benefit of physicians and patients, you’ve combined it into one big project.

We have, and I’ll give you more examples. We’ve even have a single program manager across all three campuses, select the same vendor product, kind of rework decisions along the way. We did that with our transplant solution. 

From that vantage point, we’re looking at some solutions today around radiology, because in many cases, we’re running these tests for patients across the various campuses. It’s something that we do, and we’re expanding. I will also offer that we meet on a monthly basis, and when I describe the kind of collaboration across our campuses, many organizations that are in the same corporate entity cannot get that level of cooperation.


Now that you’re on Epic and having seen Cerner recently, what would you say are the best and the worst aspects of being live on Epic?

We have no regrets about being on Epic at all. I’m going to give you just a quick sense of how we rolled out, because comparing Cerner to Epic in some ways is apples and oranges because we are using Epic differently.

I think Cerner has a good product suite as well, honestly. We think that they have a great lab system. Epic’s has improved dramatically, too. But as far as working through it, when we first embarked on the Epic journey, we had Epic in the hospital, but the doctors weren’t documenting on the system. There was no CPOE. Our ED was still on paper, Ambulatory was on paper, those 55 different subspecialties. That one primary care office we had — that was on paper, too. 

We went live with the first phase of Epic in October 2008. We took in scheduling, registration, and hospital billing. Phase 2, about a year later in November 2009, is when we got into the clinical documentation, bar code med administration, CPOE. Phase 3 was when we upgraded and we started to get into the subspecialties. But when you take a look at the doctors, it really became in Phase 2 that they got much more engaged. 

If you take a look at how we digitized, we have eliminated paper. We’re a HIMSS Level 7 organization. From the standpoint of that journey, the contract was in early 2007 and even now we’re doing different components of rolling out Epic. We’re very happy with the Epic solution. No regrets. 

As far as Cerner, we have been over the years a development partner with them, and bar code meds, we’ve been one of the first organizations. We’ve had, I think, four different solutions in here. Since I’ve been here, it was a Cerner solution and then we helped Epic as far as refining their solution. The nursing and the folks that had been using Cerner before – they came into using Epic with a point of view. 

There were some things that allow navigation that we needed to refine after we went live with Epic. At first the nurses in particular found it hard to follow the way the flow of documentation works within Epic. But truth be known, Epic is very flexible. They work with their customers. They’ve been very responsive.

Cerner, we’ve continued to be impressed with some of the innovations they’re doing around their lab solution. But because we’re trying to move to seamless, we keep working with our lab organization here, our lab department, to see at what point we can take them over to Beaker. Ultimately our aim is to deploy Epic enterprise-wide vanilla, and it has been deployed enterprise wide. But when you take a look at radiology, we still have iSite and we have Cerner for lab. There’s different boutique solutions we have out there.


What recent projects, excluding Epic, are you the proudest of?

Here in Texas, we’re just going onto prospective payment.That occurred in September of this year. As far as deploying that solution, as our organization is going through and seeing how that impacts our organization, there’s a lot of awareness that needs to be built with the clinical folks on how their documentation translates into how prospective payment informs reimbursement. From that vantage point, we’ve had a very helpful deployment. We’ve plugged in some 3M tools. The partnership between the HIM, the IT organization, and the clinicians as far as going through that transition … I’m incredibly proud of the accomplishments even at this early stage of the go-live of prospective payment in our state. 

In addition, we looked at it as a broader clinical documentation improvement program. I would say that a lot of the work that needs to be done for ICD-10, we’re at a state of readiness because we were working a lot of those components simultaneously, even though the date for ICD-10 was pushed out. I’m very proud of the accomplishments there.

We recently went live with a telemedicine solution for our NICU. Given that our organization handles the most of fragile of patients, and we have the highly specialized clinicians in our environment; we’re trying to figure out how to help the community broadly and allow children, especially when they’re in that fragile state, help them be able to stay in their community and only be flown in phone in or helicoptered in when they absolutely need to be. We have a partnership with Trinity Mother Frances. We’re deploying our talent with our NICU via telemedicine into that community hospital. In doing so, we’re finding opportunity to turn around the care of a patient within their environment.

When you talk about how pediatrics is different from adult care, the clinicians certainly see that there’s a difference between delivering care to a child versus an adult. In many cases, if you’re in a community hospital, you get concerned on whether you can deliver the right care for that child. Many cases, they’ll transport the child to us just because they’re not certain. By having telemedicine in the mix, we’re in a position to be able to give them that support that they need in their location, which ultimately leads to not only lower-cost care, but higher quality. When you talk about transporting a child when they’re in that fragile state, it impacts their health as well.

As far as that particular accomplishment, we’re getting such positive response on leveraging our capabilities around the NICU that we’re finding a number of locations across Dallas-Fort Worth that are interested in an organization that can help them in that manner. We are somewhat unique in that we’re the first pediatric hospital in Texas to achieve Level One trauma status and we’re the only pediatric facility that’s associated with UT Southwestern Medical Center.


What technologies have you planned or implemented that will empower the families of your patients?

We have several areas where we’re helping families. We have what we call the Children’s Online Experience. It’s a portal into our electronic medical record so that they can get information on tests and be able to see about appointments. In addition, we have very specialized portals based on the disease population. For example, if I’m an endocrine patient and let’s say I’m 10 years old, I might be wanting to converse with other patients that are like me in a support group way. We provide social networking capabilities in that regard as well as education on the portals.

I will also talk about one other initiative that we’ve worked with the OCR, and that’s our personal health record. While we leverage Lucy, which is part of Epic, some of this is consumer-based on whether they’re demanding or they’re interested or even asking or aware of what a personal health record is. We’ve been committed since I’ve arrived here at Children’s to support whatever platforms the patient families are interested in leveraging in that vein. But we haven’t seen it take off very rapidly.

The OCR felt similarly. They have a grant program called Ignite. They recently shot a video about some of the work that we’ve done with their Ignite program. It was a grant-funded program that we engaged in. We were the first in the nation to use the PHR where we take records from Epic and push them out to Microsoft HealthVault.  Verizon was good enough to donate handheld iPhones for our patient families that could help with sickle cell patients in Tyler, Texas. This is our initial case, and we have a number of instances across the organization, Children’s, that are interested in doing like-type solutions. 

In a nutshell, we push out the record directly into Microsoft HealthVault and then the patient family gets medication alerts for these sickle cell patients, because if they don’t take their medicine in a timely way, it’s very painful. That condition is such that if you don’t take it on a regular basis, it’s very painful. Through the mechanism of using the PHR, we’re using the medication alerts on these mobile phones. But on top of that, that patient and that family has their PHR information that’s theirs to leverage at all these different locations that they may get care delivered to them. In the case of Tyler, many of these patients, to travel to Dallas-Fort Worth. That’s a long distance. 

We’re finding that we’re doing a better job managing their conditions directly. It’s a slightly different model, but very similar to what we’re talking about with telemedicine. How do you get the care delivered to the location of where the patient family is, whether it happens to be in a community hospital, or happens to be on their handheld in a school?

There’s one other thing I’m going to mention relative to telemedicine. We’re also doing telemedicine with schools. It’s a much more sophisticated set of instruments for the NICU, but if you think of a little metal travel bag that someone might take on an airplane, about that size. It’s filled with medical equipment. A Children’s nurse goes into the school system and they’re able to deliver care to the patient in the school. At that point, not only is it helping the patient, it’s helping the families in some cases because it is a bit of a struggle when the child gets that earache in the middle of the day, and invariably when the parent comes home, they find it hard to find services.

In this case, we’re able to help the patients right in the school system and be able to leverage our primary care offices across the community to be able to deliver care without the child leaving the school and the physician can deliver care from one of our primary care offices. That’s another area where we’re reaching out into the community.

HIStalk Interviews Neal Patterson, CEO, Cerner (Part 2 of 2)

October 29, 2013 Interviews 3 Comments

Part 1 of the interview is here.

Neal Patterson is chairman of the board, CEO, and co-founder of Cerner Corporation of Kansas City, MO.

Are EMRs the center of the universe, or would a better model be more open systems that support an ecosystem of components?

I think there needs to be much more openness. Because of the complexity of healthcare, nobody, no company, is ever going to do 100 percent of the needs. There’s just too much complexity to healthcare to think in terms that you’ll have a 100 percent. 

I love seeing innovation done at the edge, whether that’s coming out of clients that have committed enough resources to do development or where we put out pockets of developers to work specifically at the client edge. There’s all kinds of needs for our systems, Cerner’s included, to be more open so that we can have an ecosystem developed around our systems.

I don’t think, though, that core chassis  of the 80 to 90 percent of the requirements that are driving the clinical enterprise … I don’t think openness evolves that back to best of breed. I think those are the core capabilities of integration are going to win over in the center of the needs. The edges should be open. There’s too many things to work on to think of it all coming out of one top-down driven organization.


If you were starting a healthcare IT company today out there on the edge, what problem would you choose to solve and how would you go about creating a business from it?

I’ve thought about that recently, not that I’m out to start another one. Somebody was starting an accelerator in Kansas City and the question was, do we as a company want to be part of it? The short answer was, we’re supportive, blah blah blah, but we stepped back one step. In that process, I actually pondered that question.

Historically, there have been a lot of niches. All of us started in a niche somewhere as a company. I’m a big fan of innovation that gets done at the forest floor. The forest floor that I talk about is when you go to HIMSS, you see the big towers at the boat show, but there’s always a whole bunch of the smaller stuff. I love the forest floor because all trees in the forest started as a little sapling somewhere. The advantage of small is you can be highly focused. You’re all in. You’re putting in all your innovation skills. 

But the reality is that in the past, a lot of people created business models and niches around all of the peculiarities of healthcare and how inefficient it has been in the past, particularly around the payment system. There’s always niches to go develop around on the delivery side. I think the inefficiencies in healthcare are slowly going away. There’s fewer targets to go start the companies at, although there’s still probably another 15 years .. find the spot in the billing system that you can help increase your revenues. I’d be real smart around NLP, around coding in this subspecialty. I think those ultimately go away. 

I think the opportunities are less. I think the home, the integration of the devices… devices, I think, are still reasonably wide open because everything is now so smart. I would try to find some edge condition around the result of that condition where it’s probably outside the enterprise. That’s what I’d invest in.


When you look at that forest floor of those companies that are trying to get a foothold, what do rules do you apply to them to determine whether you think they’ll be successful or not?

Jim Macaleer of Shared Medical Systems happened to be a neighbor of my older brother. Or my brother was a neighbor of Jim, or they knew each other back in Pennsylvania. When we did our very first venture round in 1983,  I asked my brother whether he wanted to be involved. Without asking me, he took our business plan over to Macaleer and showed it to him. And Macaleer basically goes, according to my brother, "I’ve seen so many of these and they’ve almost all failed." So I’m afraid that I might be becoming Jim. I hope not. [laughs]

I later got to know Jim a little bit and he was an outstanding man. I mean, he really was. But he had his beliefs. When he got to be a certain size, he looked back and didn’t create a lot of credence. I have a lot of respect for what people are doing. I don’t know that I’m smart enough to give you the formula which one will survive and which one won’t. It’s all hard. There’s a lot of serendipity to success, too. More serendipity typically than brilliance. Right time, right place. The art’s in the timing. It’s not so much in the idea.


Could someone today do what you did at Cerner in taking the company from an idea drawn at a picnic table to a huge, publicly traded company while retaining control after all those years?

The art’s in the timing. The window has to be there. There are these waves. As a small company, you don’t create the wave. You have to be able to see it, sense it, and then … I’ve never surfed, but it seems to fit my vivid description of what you have to do … you have to be there at the right time, at the right place. The wave has to be there, too. The wave’s got more energy than you ever can create. Somewhere you’ve got to create this leverage point of being able to get up and ride. 

You can’t take the Cerner wave because everything is unique. It was point in time stuff. You can’t use our pattern. It’s the same skill set, though. You’ve got to see the wave and you’ve got to find those convergence points of where technologies and needs and industries match. Then you’re there. You’ve got the skills. You’ve got enough to make enough payrolls to get far enough down the road.

I love entrepreneurs. I love the entrepreneur spirit. Entrepreneurs love this country. I think those pilgrims that came over were entrepreneurs of sort. They were certainly avoiding something they didn’t like in the old countries, but they were mutants where they could handle risks that most people abhorred. The skill set was common. The patterns, though, are all individually or unique to the time.

It would be a very good time. There’s more change that will happen in healthcare in the next seven years as we finish this decade than has happened in the last 70 years. This thing has to change. Change is what creates opportunity. And my gosh, this intersection of healthcare and IT … just look at the innovation in IT over the last seven years and look at the change in healthcare over the last seven years and then just say, well, if there’s even similar trends of the past equals the future, there’s going to be huge fundamental opportunities over the next seven years. 

It’s a great time to be where we are. We’ve made plenty of mistakes, but we fix mistakes. We learn from them. We also get better from it


How do you think private equity firms influence the industry?

It’s probably a little negative. My experience in that era is relatively dated. It just seems to me that there’s a lot of leashes that come with money nowadays. As an entrepreneur, the last thing you really want is a leash.


The hospital system market has boiled down to Cerner and Epic. Did Epic’s growth surprise you, and how do you see that competition shaping up over the next few years?

The first part was a surprise. They might have been a little bit surprising. They were very fortuitous in the way the market developed. Again, the art’s in the timing. Their strengths matched up very well with how decisions got made.

I think we have inherently greater strengths on a much broader basis. We don’t stay static. What you may view as a weakness today will be viewed as a strength tomorrow. That’s how we work. I’m pretty sure I was the first to use the word “duopoly” and there were people who cringed when I said it, but it’s relatively descriptive. Healthcare in IT is huge because it’s worldwide. I personally believe competition is the best thing ever invented. Competition drives, accelerates innovation, it creates value for our clients. If you don’t respond to competition, you’re eliminated. It deals with the survival of the strong. 

We are strong and we will get stronger. In every era, we’ve had major competitors. We go back to the lab days. I cannot tell you what exactly happened to Sunquest. I didn’t track it all. I’m just finishing a note, what I call a Neal note, to our associates. I have the HBOC story in there. We usually do our town halls right after our health conference. The associates we could get, we’d get them all together and we had basically a town hall format with a question and answer period. We were using an outdoor stadium and it rained on our town hall so I had to call it off. I told the story that the last time I had to call a town hall off because of weather was back in 1998. I went on to talk about the head-to-head match with HBOC and how tough a competitor they were and how many people declared them the winner. We’re going to do fine.


Epic draws the contrast saying that they don’t do sales and marketing and the product just flies off the shelf on its own. What is your thought about the role of sales and marketing in something like selling healthcare systems?

Frankly, I think there’s a lot of things that have been stated by that company … I think sales and marketing are healthy parts of an economic enterprise. I don’t know if they’re trying to make that bad or evil.

This business ends up being a relationship business, because I don’t know of another relationship or healthcare delivery organization formed that’s more important to them than the relationship we end up with. You’ve got to start that relationship somewhere and people have to learn about you. I don’t know what you call that. I don’t believe any company that has grown a lot doesn’t have that.


How would you describe your management style?

I make sure I have a great team around me. I mean, a really great team. Then my objective is, in the perfect world, that the organization is so well designed that there’s nothing for me to do. Now I’ve never even gotten close to the perfect world. I say that somewhat jokingly in a sense. Goal One is to create a great team that can operate without you. 

Then I do two things. I look at chunks of my time, usually about 100-day chunks, and I say, what do I need as the leader to get accomplished in that 100 days? Then I design everything about me to work on what comes at the top at the list for the next 100 days. That’s how I do my calendar stuff. The test is that the rest of the organization is working well. 

I’m kind of a free safety. I touch the things that I think that need to move internally, that I go then drill down. Another style I have is that I get very deep. When I want to understand something internally, I’m not going through the chain of command. I’m going down to where the work is and I get pretty deep. I tend to be in the room when we’re defining the three-, five-, and 10-year views of what we’re going to accomplish, too.


Intermountain Healthcare had an agreement with GE Healthcare similar to the one Cerner just signed. That didn’t seem to produce anything much for either organization. How will the company work with Intermountain in developing something that’s both useful to them and that has market value for Cerner?

I think they learned a lot from their GE endeavor. Their intent wasn’t to go develop something unique. Their intent was to basically go to a marketplace and build a relationship around a company that can meet most of their needs today. The foundation of that relationship wasn’t to go build something, it was to deliver something. 

The flipside of that is that this is a very innovative, creative organization and entrepreneurial organization. We’re going to go build the first real costing system this industry’s ever had, working with Brent James and his institute, around building an activity-based cost system for healthcare. There are some specific things we’re going to go innovate together with them. Their large body of work over the last couple of decades around process models will certainly be a source of content for us and our other clients. 

They changed what they were trying to accomplish with the relationship significantly. They wanted to go to the current marketplace and buy the best solution for them that’s available in the marketplace today. That was how they made that decision. It’s a neat organization.


I assume it’s similar to the agreement or the arrangement that you have with UPMC with also a lot of innovation and entrepreneurship coming out of a non-profit group.

UPMC is a great client and great innovators. They are amazing as well. We have a good relationship with them, but we’re at different points in time between the two. I don’t try to compare the two.


When these agreements are struck, it’s always between large, prominent healthcare systems and vendors. Do you think that that’s the right kind of information or outcome that will be useful to the average 300-bed community hospital, or should somebody be forming a relationships with smaller places that are more prevalent in number if not in stature?

I’m extraordinarily pleased with the level of collaborations we are doing throughout the industry. It’s not all with the megas. The work we’re doing with Advocate, a large system, around population health is real cool. I mean, that’s the largest ACO in this country. They pioneered the whole concept of clinical integration, which is the backbone to how you manage the care side of a population health system. They have 500,000 lives where they’re risk for, defined risk of a population attributed to their health system and down to individual doctors in their health system. 

The other side of it is we announced recently an institute at Children’s National Medical Center, which is really this notion of development at the edge. We’re using them around pediatric populations. We have an institute at the University of Missouri, which wouldn’t be considered a mega client, but it’s a three-year-old collaboration where we are focused on the adult population. Then we have an institute up in Canada, I think they recently rebranded their health system but it’s Island Health in Vancouver, that focuses on the elderly. If you think of those three institutes, those aren’t your megas that you referenced.

We love where we clearly create an alignment between us and another organization and there is a specific area of interest and they have an attitude that toward innovation and development inside their health system. We jump on that. We have a whole model around that. I’m just very pleased with the depth of that and how productive that’s all been. Intermountain fits into that broad category of defining strategic relationships.


What’s the long-term plan for Cerner and for you personally?

There is a new layer of information, a new information model and technologies and platform around it, that’s growing up above the EMR that’s fundamentally designed to manage the health in a population and to support enterprises that can get closer to the first dollar. If you compiled that fairly concise set of three or four items we covered, it gives you what I believe we’re going to have. 

I think we can synchronize the activities of a complete system around health and care and synchronize it and be able to through different organizations deliver predictable, guaranteed levels of care. I call them SLAs, the same as what we do in our data centers. Here’s the performance that you can expect from that system. Here’s the measurements that are useful.

There’s a new middle that has to be created in healthcare. Healthcare is this inverted thing — it’s all delivered local. You can get on an airplane and fly someplace, you can change the ZIP code, but it’s delivered local. From the ZIP code up, there’s just a huge amount of opportunity in healthcare. It’s the largest sector of the US economy. It’s typically the largest sector of every economy in the world, the exceptions being India and China where the investments haven’t been yet made. The needs are very, very similar worldwide. I think Cerner’s got a huge future.

As regards to me personally, I said at the beginning of the decade that this is the first decade that I start as CEO that I don’t expect to end as CEO. That’s a function of age, not a function of desire or anything else. It’s just kind of a reality. There are things in nature you do not change. It’s also a statement of confidence of how strong a team I think we have at Cerner.


Any concluding thoughts?

As we finish this decade, I think we’ll look back and say, this was the key decade that many people predicted over the last three decades, that there was going to be fundamental change and transformation in healthcare. I believe it happens inside this decade. My basis for that will be repeats of what I said previously, but I think the ability to finance an ever-growing expenditure of healthcare is decreasing rapidly. I think the need to transform it is here and I think the largest lever that you can have to change healthcare with IT. 

This country and many other countries have invested significantly in IT, and we as providers of IT will collaborate with our clients around using that lever to fundamentally change the cost structures and the quality that’s produced. I also believe that there will be a fundamental change in business models, and providers will be much more integrated on vertically on how healthcare is financed, and they’ll be more accountable for the health of populations. 

This is a significant industry and I’m extremely excited to be part of it. I feel very privileged.

HIStalk Interviews Neal Patterson, CEO, Cerner (Part 1 of 2)

October 25, 2013 Interviews 5 Comments

Neal Patterson is chairman of the board, CEO, and co-founder of Cerner Corporation of Kansas City, MO.

10-25-2013 12-46-05 PM

We have somewhat questionable healthcare costs and outcomes even though we’re spending a fair amount on information technology. What are we’re doing wrong as an industry?

I believe that IT is the single most strategic lever that healthcare can use to fundamentally change the cost structures and the quality of the service and the solutions they provide. It’s a lever that needs to have an impact.

If you look at other systemic things that are not working right in healthcare, the other one would be how healthcare gets paid. There’s not a business model for health. This all reinforces the reactive, volume-based care model.

So one side is broadly a policy change that could be effected through policy; it could be effected through the marketplace, too. The other side is this huge investment that our clients around the world are making in healthcare. We need it to be more of a strategic lever to change the fundamental results of their business. Those are two things that come to mind as to if you could change something in a relatively short time that would have the biggest impact — how people get paid and how they strategically use IT.


Are you encouraged by the change in policy direction?

We’re in an era that does create a bit of chaos, but it’s an era where there’s a lot of experimentation. I’m fairly optimistic that it will formulate into a cohesive policy. We have to get through this era. Our government is out of money, as evidenced by the news from last night, last week, last month, around the deficit we’re running. We’ve got to get through that era where real policy could be formulated. But I certainly do like the experiments that have been run around accountable care, around value-based care, even around bundled payments. We do need change in how healthcare is paid.


Healthcare is political, and one person’s excessive costs is another person’s livelihood. How would you fix it, given that so many special interests that are fighting over those dollars that everybody hates to spend, but that everybody likes to take in?

It unfortunately has a lot of politics in it. I don’t like this part, but it’s fixable, because there’s the single buyer.

Wal-Mart’s impact on retail, we have the same thing … we have a Wal-Mart in healthcare. Our federal government buys so much of healthcare that if they get it right, it will change. Even though it’s a complex system and there’s an unbelievable amount of variables, there’s a single leverage point that would create a huge incentive.

At the Cerner Health Conference, I did what I openly called a few Neal rants. [laughs] I said that some of them are going to be directed at my dear clients. In reality, most of the progress, certainly the rapid progress, made on the IT side has been because they were paid to do it. That’s my broad criticism I make on healthcare — unless somebody pays you to do it, you really don’t. There isn’t the strong instinct to fight the barriers to make the fundamental change.

Just take sepsis as an example. The algorithm to predict that someone is going septic has been available for decades, We’ve for decades known the variables in that algorithm, and it’s fairly well published. With many IT systems, certainly ours included, you could implement those predictive models, and with the current decision support, fire off the alerts and actually save lives. Much of that didn’t happen until there were strong external incentives. 

I’m optimistic in the sense there’s a single leverage point to fundamentally create systemic change in healthcare. The investment in IT gives the capability of making systemic changes to healthcare. There are two leverage points. Unfortunately, one of them is tied up in politics, which isn’t my favorite subject. [laughs]


Along those lines, the federal government dominates the R&D agenda of Cerner and every other vendor because of the requirements for Medicare and Medicaid billing and now Meaningful Use and ICD-10, not very much of which has any positive impact to patients. Do you see that changing?

I’ll speak for Cerner. The federal government’s requirements through Meaningful Use, ICD-10, and the much larger list of compliance when you add all the FDA and all that, that doesn’t drive our investment agenda around IP. We certainly have to cover that.

We had a new business client make the comment that with the other companies they went to, their focus was Meaningful Use requirements. it was a multi-day session with us and the guy says, “We have not heard the word Meaningful Use once from you guys.” It’s because it isn’t that we didn’t have work to do — because when you get the specific requirement, you’ve got to convert to the specification – but I didn’t think Meaningful Use was that high a bar. We’re not being driven by that. 

Frankly, ICD-10 was in our systems in Australia 10 years ago. Was it embedded in all of the third-party reimbursement and documentation methodologies and impact or revenue? No, but our core capabilities were there 10 years ago.

I was in a session within the last year, I think it was last spring. There were like 20-some counterparts or near counterparts in the room. Whatever the good fortune was, I ended up being the last to speak. [laughs] I didn’t plan, I wasn’t exactly driving it, but it was the way it worked. Everybody else in the room, all the other companies — and it was a government-based meeting — everybody went around and said, here’s the impact of all this on themselves, on their companies. Everybody basically was whining. I’m the last to speak. I turned to my counterparts and said, I don’t get it. We’ve been given a gift. There has been a huge acceleration in adoption of IT. There’s huge progress around standards. If we are good, we’re about to create a golden era, the next golden era of healthcare.

I don’t know why everybody’s complaining. It was a gift. Now I’m probably going to get myself in more trouble. [laughs] We’ve been given a gift from the IT side. It’s not a burden. These are not that high of bars. The opportunity to create this golden era is sitting there. That’s what excites the heck out of me and drives me. Because when we do get the new business model, where you’re really responsible for the health of a population, not reacting to the care needs, that’s an exciting era. We’re investing heavily in it. And it’s not a Meaningful Use requirement. [laughs]


Do you think in that change toward that population health-type model that patients will gain leverage instead of being almost a bystander in their own care?

I’m going to take an indirect route to answering that. I think one of the positives of the exchanges is that it basically connects the person to a marketplace. It’s a marketplace of decisions around healthcare, what level of benefits do you want, blah blah blah. In essence, it’s creating connections of individuals to making decisions healthcare. I think it’s fundamentally important.

I do believe Meaningful Use requiring fundamentally a patient portal to get access is really a nice step, too. Increasingly, I think people have higher expectations of being able to get minimum access to a record.

Then I’ll hit the third leg of the stool. I think you probably know this, but we do a fair amount of work at the employer level. We certainly have used Cerner in our workforce, in our health plans in this country, as a laboratory on how to create engagement at the employer-employee — in our terms, associate – level and their families. I think we’re part of this pre-era of getting people involved in healthcare.

We’ve got three important legs playing out right as we speak. It isn’t a solid platform yet. I believe that we’ll never get to true interoperability without a service that will provide identification across providers and across IT platforms. Our purpose for being involved in CommonWell is interoperability.

We’re in a pre-era of having alignment around forces that will create an environment where those who choose can be fairly engaged at low-cost, low-friction ways of being engaged in their own healthcare. All the way from trying to be well, to making this economic decision, which is one of the things that has been missing. The exchange is that part of the stool. Down to the Meaningful Use patient portal, even though it doesn’t solve the ID issue.

The important era we’re in, I think it comes together this decade. The reason I strongly believe that is it goes back to the deficit. We have no fundamental choice other than to socialize the system in the US. Our choice is to produce higher quality at lower unit cost and to start focusing on health-related ways of minimizing the prevalence of highly costly conditions and patterns in society.


Vendors and providers really have never been trained to think in terms of managing a population. They were raised in an era of managing an episode of care. Is that going to be a tough transition?

Not really. There’s been a lot of change since the ‘90s. Health systems have gotten to a more appropriate scale. They have better management leadership. Many of the leaders have a vision of a direction this size. They’ve got size, scale, and better leadership. The IT investments they’ve made and the degree which they have been driven into the clinical process is significantly different this decade than it was back in the ‘90s. Twenty years has made a lot of difference.

The problem is the layer above them. The providers have been conditioned to let someone else aggregate their populations. That’s been the insurance companies.

With their size and scale of providers and if you change the incentive structure, I think many of them will be positioned in the last half of this decade to get most of the first dollar of healthcare. Then they have the incentive.

It’s bipolar. Once you have the first dollar, your incentive is to keep people out of your facilities, out of your emergency rooms. Keep them as healthy as you can, because you’ve got the dollar. It’s bipolar. It screws up your behavior. But I don’t see any other way out.


Do you believe the hype around big data and what value it will provide in this transition?

Yes and no. You certainly have to give Amazon credit for knowing their customer, knowing what they’ve done in the past with that customer, and making sure that they create as little friction as possible to repeat business. Is that big data?

I think big data is a grossly overused term. It is understanding patterns, finding algorithms that you can embed that predict repeating those patterns. Is that big data? I’m OK calling it that. It’s not my favorite term. I’d love to hear your answers to all these questions. [laughs]


We’re not as population health-based as most other countries. We like the idea that our healthcare is individualized and personal, that we don’t want algorithms or even to some extent evidence-based medicine. What will take to get people to buy into the concept that there are certain things that make perfect sense to society, such as the science that said mammograms are not effective in certain groups, and yet everybody threw up their arms and said, no, we want them anyway?

I think that’s pretty clear. When you don’t have information about the members of a population, all of your rules, all your algorithms, have to be based on the entire population. There’s no personalization of it. That’s where you get the mammograms at 50 problem. All of us, being part of the population … having two daughters and a wife and one granddaughter, I want the algorithm, but I want it personalized to every individual in my family. I don’t want the algorithm that has to treat the entire population as one.

I want the algorithms. I desperately want the algorithms. I was thinking deeply about this yesterday, because I was involved in the care system with my wife. I was sitting there talking to really smart people about the response to this drug and this type of case. This broad pattern, it’s not her, she’s in a population. But the reaction of this drug to that population, it’s not just probabilistic. I mean, 70 percent of the time it works, 30 percent it doesn’t.

I know for a fact that most of that could be much more precise, much more precision in that if you go down to the genetic level. Take that phenotype from the genetic record that you have and build your models at that level. It won’t be us as consumers because I don’t want the mammogram at 50. I want the algorithm that says for you, for my daughters, here’s when you should start having mammograms. We’re going to get there. It doesn’t seem like big data to me. It’s finding the patterns and then building the algorithms.

The group that’s going to have the problem with it isn’t the consumer, because we will as consumers eat up the fact that you’ve taken that drug and you can predict its response against me as an individual because you have my DNA and you know what pathway that thing activates down at my genetic level. The people that are going to have trouble with this is the medical profession, because to them evidence is simply graded opinions and the highest-graded opinion is a blinded study with an adequate population that has a certain standard deviation that has been run and vetted through an editorial system. That’s the Grade A evidence. Well, these algorithms are never going to go through that process.


How do you see that being incorporated into electronic health records?

The first thing that has to happen is, as I’ve always said, you have to take the phenotype and the genotype and put it into a common data model. We broadly did that well over a decade ago. We’ve got to get a common data model.

The other piece of it, though, is going to be above the clinical or personal or health record. There’s a lot of other data about us and about our health that need to be included in the broader model and need to be included in the patterns.

I admit that I spent several decades arguing the case that said the EMR itself was much more powerful and predictive set of data than the claims data. I for the most part have won that argument. But that doesn’t mean that the claims data shouldn’t be in the data model itself. Because of the surveillance capabilities of other data sets –claims, PBM data, and frankly employer enrollment data, the stuff that’s generated out of my home.

We’re in the middle of a weight loss contest. My scale in my bathroom, when I stand on it, it hits my personal record and it also updates the competition that I’m in. That record itself is going to end up being larger than the EMR.

The other data is going to be included in many of the algorithms, plus the GIS-type data. If my son was asthmatic, they should know the level of the pollen count and other measures of pollution in the community, which will be included in the prediction of how good a day he’s going to have and whether he should be taking an inhaler to school or not. Or should he actually take the inhaler, because it’s easy to predict you’re going to have an adverse event without the inhaler.

That other data doesn’t go back down to the EMR. It doesn’t fit. It wasn’t ever designed. What I said at our conference was that at the end of this decade, your view of the EMR — yours being our clients’ view of the EMR — will be similar to the way you in the audience view our laboratory system today. I grew up doing laboratory systems, I love laboratory systems, we still do laboratory systems. It’s exciting, but it is not strategic to the enterprises that they are members of. It is not the strategic system. 

The strategic system in the future is going to allow you to manage the health in populations as well as predict the care needs they have. When people do arrive, you have the resources there. I probably went as far to say the actual EMR is going to be kind of like, “I can’t tell you for sure what lab systems that many of our clients use” because they’re integrated into the data flow, the trigger events or the mapping has been done to convert to a standard nomenclature.

There is this new layer that’s coming in our industry. It will have a profound effect on people’s view and strategic view of information systems, it will change quite a bit.

I went broad there, but the genotype does belong inside the record. It is different kinds of data. It’s enormously different kinds of data. We have to merge the genotype and the phenotype, but we’re going to also conduct the instrumentation of the home, my wearable instrumentation, the data that is relevant to different health needs coming out of the environment in my community as well as other systemic systems that can trigger key information such as claims, PBMs, whether I get my prescription. I know from the EMR that I wrote the prescription. I need to know whether it was filled today. That data we may bring back into the EMR, but the reality is that it will all blend together.

Part 2 of the interview will include EMRs as the center of the universe, how to start a business today, the influence of private equity firms, thoughts about Epic, management style, the Intermountain partnership, and long-term plans.

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